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t � �l 'a APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) ; 1 ade to the San Joaquin Local Health District for a„permit to construct and insi'all the work her Application is hereby mein described. This application is made in compliance with County Ordinance No 549. JOB ADDRESS A D 'LO ATION___ --q--!---- -- ------ - --- Owner's Name---- --- ----- ---------------- -------------- --- ------- -" ----- - ---------------------------------- Phone----------------- ------------------- -- rt --------------------------------------- Address ---------------------- Address_.._____'---- - - - --- ----- - -- - -- Phone -------- ----------------------- Contract�or's Name-- ---.,:�,�------`--------- ----------------- ------- -- ---- ----- - ---------------------------------- - - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court El Motel ❑ Other 1:1 Number of living units: umber of bedrooms T Number of baths ] Lot size________ ___ , Water `Supply: Public system {Community system ❑ Private ❑ obe /Hardpan ❑Cla Loam Clay ❑ Ad Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ y ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet. Mat L, I---- - -------- --------- ------------- Distance fro ..foundation___."___ __ -�-- Septic -Gunk- Distance from nearest well_ _-_________ x yC Liquid depth_____- __'.__.--"-______ �/ - �---Size------------- -------- -•--- q No. of compartments----------�-----------CapacitY----- -�- Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining materia------------------------------------- Cesspool: ______________--- ------- -- ------- ❑ Size: Diameter--------------------------------------Depth----------- -------- ------- -------- - ---------- _Distance from nearest buiidin Distance from nearest well-------- ------- ------ - ----- --------- 5:--_- -•----- -----._.�-- _• Privy: - _ .,.� ❑ Distance to nearest lot line_____,--------------------------------------- Seepage ------- --------------------------- - - Distance to nearest lot line___ -_____-_ Seepage Pit: Distance to nearest well_,___________________Distance from foundation----F&_ ---- ❑ Number of pits----------------i-----Lining material-----------------------Size: Diajm. er-----------------------.Depth---------------------------- Distance from foundation_ _` "------Distance to nearest lot ling Disposal Field: Distance from nearest we I___ +1 1�. �- _ - ,-Len th of each-line-- Number Number of`lines--- ------ g t ---- De th of filter material_________ -----____-- Type of filter material'_ �_�l -. p Remodeling and/or repairing (describe):------------------ ------------------------------------------------------------------------------------------------------- ----------------------------------------------- -—--- ------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin oun y ordinances,/,State laws, and rules•*ndregulations of the San Joaquin Local Health District. (Owner and/or Contractor) J[Signed_ _�� Title ------------------- ------------------ -- -------- --- --------- - ------------ - - -- BY- [Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). ; FOR DEPARTMENT USE ONLY ----------- ------------------------------------- DA7E---�----- - ---------------------------------- APPLICATION ACCEPTED BY-------------- ---- DATE------ REVIEWED BY----------------------- ------- -------- ------- ---- ----- --- -•- - DATE_ - -----------------------------------------ILDING PERMIT ISSUED Na-> ------------------- Alterations and/or ecom endations---_______ � --- '---- ------- - -- ---------------------4---- ---------- i ------------- ----------------- ------------------------------------------------------------------ -------------------------------------------- -------------------------------------------------------" 7 ,S ��- ---5-�----(Date) FINAL INSPECTION BY:----- -- ------� ---------------+------------- --------- PERMIT No.__�D------------ ISSUED_-------/----� d Date------- -------- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639 ��