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APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) C �'— d �- Ug <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install thrork herein described. <br /> This application is made in compliance with ounty Ordinance No. 549. <br /> J A DRESS AN LO ATION- � 4U515_DY� r�► .+ 1-`I !1_/P!)�r �ISA�TI._L�/Q' <br /> /l C 1J /� ice ' <br /> Owner's Name----- _ 1 C 1°1�--------------- ` Phone -�� <br /> Address-...--- -- -------------------------------------------------------------- <br /> Contractor's Name--------------- --------- -------------------- — =------------------------------------------------------------------------- Phone_----------------- <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: [1 ;Number of bedrooms E� Number of baths Q Lot size----- ---------------------- <br /> Water Supply: Public system ❑A Community system ❑ Private X <br /> Character of soil to a depth of 3 feet:`°-'Sand ❑ Gravel [] Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hard an <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> w Septic Tank: Distance from nearest well!__---__-Distance,from foundation---�__U' Ma erial___--- _________ _____ <br /> No, of compartments _.._ uu -=----- <br /> p, ------------Capacity--•:-•---------------Size---_�-----X-1--------..Liquid depth --' <br /> 40 <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__--_--------_--------_-----_---_---- <br /> 0 Size: Diameter--------------------------------------Depth--------------------- ---------i-- ------------- <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-_--- ----I-- .Distance to nearest lot line----_-__------_- <br /> ❑ Number of pits------------- --------Lining',naterial-----------------------Size-: Diameter--,u ^-----------.Depth---------------------------_-_--- <br /> Disposal Field: Distance from nearest well-�__ _-_-Distance from foundation_d- Distance to nearest.lotjine--:6�/------ <br /> Number of lines--------1--__ of each line.._l.� a_ _ Width of trench ---- --------------- ------ <br /> Type of filter material _ -- Depth of filter material__ ------__ - R <br /> Remodeling and/or repairing (describe):----------------------------------------- -----------------------------------------------------------------------------------_------------- <br /> h <br /> ---------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and' re lations of the S n Joapuin Local Health District. , <br /> "(Signed): = _ _.._-.... = _ = _ - )Owner or'Contractor <br /> rrac <br /> � t � <br /> By:---------------------------------- ------- ----------------------------------- ---------------------------------------------(Title)-------------------------------------- <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 /> APPLICATION ACCEPTED BY ------------- 7_0y DATE ` � <br /> REVIEWEDBY----------------------------------- -------------------------- -- ------------ DATE---------- -Y- ::---------------- <br /> BUILDINGPERMITISSUED----------------------------------------------------------------------------------------------------- DATE----------------------------------------- •------------- <br /> Alterationsand/or recommendations-------------------------- -------------------------------------------------•---------------------------------------•-----:__----------------------------------- <br /> ----------•--------------------------------- -----------------------------------------------------------------------------------------------1____1-------------------------------------------------------------------------- <br /> = -----------------------------=-----------------•------------------------------------------.-----, ------ ----------------------------------------------------- <br /> ----------------------------------------•:---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------- --------------------------------------- -------------------- -- --------------------------•-------------------------------------------------------------------------------- i <br /> : , 1 <br /> PERMIT No. - -------- ISSUED -(Date) FINAL INSPECTION BY- <br /> 4__ <br /> Date---------------- . ---- ---------- -- ---•-----------....- i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> 130 South American Street <br /> it Stockton, California <br />;� ES-9-2M 9-50 W=1639 <br />