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APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> t - ------------------------ <br /> JOB ADDRESS AND LOCATION----------------���--- --� ---- - ------------------- - ---------- --•------------------------------ - <br /> Owner's Name----------------------•-------- ���` - - ---- ------------ -----R't r/a---------------------------------------------- Phone------------------------------------ <br /> Address--------------------......--------------------------3d2__k---- ------------------------------------------ <br /> Contractor's Name D,_jp�------•--,'-v -------------------------------------------------------------------------------------- Phone �- '�— <br /> Installation will serve: ResidenceS*jNumber <br /> Apartment House E] Commercial E] Trailer Court ❑ Motel Other E]Number of living units: of bedrooms 5"" Number of baths [P Lot size------------------------------------------------------------ <br /> Water Supply: Public system ❑ Community system ❑ Private IV �9 <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe KHardpan ❑` <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well--_" ""°-----Distance from foundation--------------------Material----------------_-----------------___--------- <br /> - Q7_ No. of compartments--------------------------Capacity-----------------------Size-------------------------------Liquid depth-------------------------- <br /> Cesspool: Distance from nearest well---'.-Distance from foundation--------------------Lining material----------------------------._------. <br /> Size: Diameter-------------------------------- ----Depth-------------------------------------------------•-- <br /> Privy: Distance from nearest well--------------------------------------------------Distance from nearest building-_----___---_------------._--------_--- <br /> Distance to nearest lot line------------------------------------------------ <br /> Seepage Pit: Distance to nearest well-------------- ------Distance from foundation--------------------Distance to nearest lot line-------------_--- <br /> Number of pits----------------------Lining material-----------------------Size: Diameter---....._------_---,---.Dept h------------------------ � <br /> Dispo 1 Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> Number of lines-----------------------------------Length of each line------------------------------Width of trench---------------------------------- <br /> Type of filter material-------------------------Depth of filter material----------------------- <br /> w <br /> Remodeling and/or repairing (describe --------------------- ..... ---------------- ---------.��------------------------- --------•--------- <br /> --- -- ------ - ------ -- - -__ - _-_- ---------------- - -------__------__-__-_-.. ----------------------------- <br /> --------------------------------------------------------------- -__- ---------------------------`--------------------------------------------------------------------------------------- <br /> hereby certify +hat I have prepare is application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Statex <br /> nd rules and re <br /> tions o San Joaquin Local Health District. <br /> V <br /> l ----------------------(Owner and/or Contractor) <br /> (Signed)--- ----------------------- ------------------------------------------------------- <br /> By:------------- ---------------------------------------------------------------------------------------------------------------------(Ti+le)----_-_-------------------------------------------------------- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> -------------- DATE------/ �- /'o-------------------------------------- <br /> REVIEWED <br /> ~-`--------------- <br /> APPLICATION ACCEPTED BY. --- ----------------------- ---------- ----------- ------------ <br /> REVIEWEDBY-------------------------------------------------------------- ------------- DATE------/ !' 'S' --------------------------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------- --------------------------------------- DATE------------•-- -------------------------------------------- <br /> Alterationsand/or recommendations:------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------------------------••-------------------------------------•----------------------------------------------------- ---------------•-------------- <br /> PERMIT No-----11--- '--•-------- ISSUED----- ----------(Date] FINAL INSPECTION BY---------------- } ----------------- --------------- <br /> Date---------------------------------r------ .--•`3-v------------..- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />