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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. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION.- - � ----------- Owner's ---------Owner's Name-- -:- .-___-- ,,+. __ --- Ph --- ,.�:- - -------- - -- ------------ ----------------- one------------- ----------------------- Address ��---- Contractor's Name---- --`--- ----- �---- ---''tl� � � � -------------------------------------------- Phone_ ��✓� �___�____ .Installation will serve: Residence V Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms IP_ Number of baths 0 Lot size----- 10___ Water Supply: Public system [ ' Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Yo Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: w (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material No. of compartments Capacity Size Liquid depth ------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- 0 Size: Diameter---------------------------- --------Depth--------------- ---------------- ---------------- -Privy: Distance from nearest well--------------_---- __ --- -------Distance from nearest building Distance to nearest lot line________________________ ------Seepage Pit:Pit: Distance to nearest well-----------_�---Distance from Distance to nearest lot line_____ fou dation-_---- d /� --____--_-, _ Number of pits---------/__------_-Lining material---&4.-2'_. �_sSize: Diameter----- , _`� - -----.Depth------a�_�------------- .Disposal Field: Distance from nearest well-----2snrm--_Distance from foundation_ . d _-__----Distance to nearest lot line---�-�7_--__ Number of lines-------___ ____ f� ____Length of each line------ Q Width of trench_-__2__S _"------------_-_ Type of filter material--- ,, ---__ Depth of fitter material__-��_"_______ -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 County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)--_0_,A---f----� 1----- - -- _ --------------- ----- Queer-end/or Contractor) ------------------------:- ------------------------------- By --- (Title) ------ -------------------------- P of plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- --- ----� j-------),---------------------------------------------------- DATE-------- t/ ----------------- REVIEWED BY----------------------- --- ------------- --------------- - --------------- - -------------- ----------------- DATE------ ------------------------------------------------- I DING PERMIT fSSUED --------- DATE --------------------------------------- -------------------- -------------------------------- Alterations and/or recommendations---------------------------------- -- -- ----------------- --------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- ----- ------- -- PERMIT N ----------- ISSUED---- '__-! p -Fl-- -�/-------(Date) FINAL INSPECTION BY:___-_____�____�_ -___---__ -------------- Date--------------------- ' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street E5-9-2M 4-50 W-1634 Stockton, California