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APPLICATION FOR SANITATION PERMIT '! (Complete in Duplicate) _ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. f This application is made in compliance with County Ordinance No. 549.Lj 51 _-.- --- - � B ADDRESS AND LOCATION -d_-3 -cry- Owner's Name------�+_ -------- ---------- ---- --------------- -- ----- --- - ---------------------------------- ---- --- - - -/--- Phone-- Address------------ - -_ k--- - f - Contractor's Name------------------------------- -------- - ------=---- ----------------------------------------------------- Phone----------`--- ------------------- Installation -----Installation will serve: Residence [}Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ F E Number of livingunit s: ---- l ;� -----_-- _ - - ---- < _---._-�Water Supply: Publics stem ❑ Community system ❑ Private �- Character of soil to a depth-of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam . Clay ❑ Adobe❑ Hardpan TYPE OF INSTALLATION AND SPECIFICATIONS: _ .- (No-septic-tan k=or-cesspool-permitted-if public sewer is aila�le'wit=moi n 000�feet.) Septic T k: Distance''from nearest well----- -_-,Distance from foundation--------------------Material------------_------------_-_-----------------_-. No. of compartments----------�?----------Capacity---------�----Size--------5--..'C-_7_.--------Liquid depth___--5-_"-_ Gesspaal'- Distancel from nearest well-_ -Distance from foundation--------------------Lining material-------------------------------------- ❑ ---------------Depth---------------------------Size: Diameter----------------------- ------------------------ ;Privy: Distancefrom nearest weii-------------------------------------------------Distance from nearest building_-----_---------.,----__-- _----------_- ❑ DistanceiPto nearest lot line------------------------------------------------ f Seepage-Pit: Distance Ito nearest well_-__f--- -------------Distance from foundation-------------------.Distance to nearest lot fine----------------- Number ------------_-- e _. . ,❑ Numbersof pit-s----------------------Lining material-----------------------Size: Diam_ete --------------------.Depth----------------------------- -Disposal -----------------------•---- :Disosal rest �---..Distance-fromfounda+.ion:-:'��..Ir--Distance to-:nearest-lot-linom_: f t Number of lines-------.--fir--------------------Length of each line------------------_ Width of trench------;P�"'A------------------- Type of filter material---------•---------------Depth of filter material-----1------------ -Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------------------------- ------------------------------------------------ d --------------------------------------------------------------------------------------------------------•----_-------_-----------------------_-----------••------- I '-- --------------------------— ii----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of th San Joaquin Local Health District. - F r (Signed} =-------------------- --__, __ __------- -------------- -(Owner and/or Contractor) . ....a-�-�--- ---- �•-- - ' (Piot plans, shoving size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). 4 ' FOR DEPARTMENT USE ONLY APPk REV ACED BY ACCEPTED 'BY------------ ----------�-.�-" �-,,.�.----...�'-.._� -----------------. DATE-------------- ----------------- ---�---�------f ' --"--------------------------------------------------------- -------------------------------------------- DATE BUILDINGPERMIT ISSUED---------------------------------------------------------I------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations--------------------------------------------------------------- ----------------------------------- ----------------------------------------•-- r r ------------------------------------ -------------------------------------------- ------------------------------------------•---------------------------------------------------------- --------------------------- --------------------------------------------------------------------------------------------------- ---------------------------------- ---- ------------------------------------------------------------------------------------------------------------------------ ----- -----------------•--------------------------- PERMIT No - - SUED - � -- - (Date) FINAL INSPECTION BY-- ------------------------ `--- IS -------- ------ Ff Date-------- -------------_�-7-------- �---- --�- / SAN JOAQUIN LOCAL HEALTH DISTRICT + 130 South American Street Stockton, California - E5-9-2M 9`50 W-1634 t