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APPLICATION FOR SANITATION PERMIT Z (Complete in Duplicate) J 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. 5494 "' 4Z_ 1. JOB ADDRESS AND CATION_ ______ Z ... ..... ____ y f Owner's Name---------- ---- - ----t-------------------------------------------------------------- Phone.,/ '` !1__ Address----------¢�.- 4(,o 'A------------ --------------------------------------------------------------------------- , Contractor's Name-------- --- Phone_ "'f'*~�+`�-"`------- Installation will serve: Residence% Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑/ pOther F1Number of living units: (� Number of bedrooms [:1 Number of baths [ Lot size___ _x---1__9____�----------------- ____ Water Supply: Public systemf Community system F1Private E] Character of soil to a dep+h of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan t TYPE OF INSTALLATION AND SPECIFICATIONS: # (No septic tank or cesspool permitted if public sewer is available within 240 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------------------------------------- F-I Size: Diameter--------------------------------------Depth---------------------------------------------------- Privy: Distance from nearest well--------------------------------------------------Distance from nearest building_______--________-.-_________-__-___---.-. ❑ Distance to nearest lot line------------------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- Disposal Field: Distance from nearest we l __.Distance_from foundation19-0__r_______-Distance to nearest lol line_ _- I . 10 Number of lines__________ ___ ___ _____ Le hof each line____�)---- Width of trench___��_______________________ ' Type of filter material_ __________ _________ epth of filter material---4�---_____-_____ i Remodeling and/or repairing (describe):----- � ._ a --- ------------------------------------- --------------- ' ---------------•--•----------•-----•--------------------------------------------------------------------------------------------- �A - ---------------------------•------------------•--------------------•-•-------------------------------------------------------------------------------------------------------•------------------------------------------------ -------------------•-----------------------------------------------------------------------------------------------------------------------------------------------------------------------••-------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances s a la acrd rule and' re ulati ns of the San Joaquin Local Health District. 7 (Signed t - --------------------------------------------------------------------- ----------------(Owner and/or Contractor) By:--------------------------------------- ---------------------------------------------- ----------------------------------------(Title)---------------------------------------------------------------- (Plot - ----(Ti+le)---------------------------------------------------------------- (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 APPLICATION ACCEPTED BY----------- ---- ---- - -------- t_ .".." DATE "� REVIEWED BY V DATE r - --------------------- ---- --------------- -------- ----------- BUILDING PERMIT ISSUED--------------------------------------- - ----- DATE-- ----------------- Alterations and/or recopnmendations_________ __ _ ___ -------------- -- -- -- " --------- -- ----- ------- -------- ---- --------------� ------ ----- -------- > --------ma c ---- ---- ----------- - * _ --6.1- _ __________________..__-_ _ _________ -__ __ _ ________ _________ti_____________________________ ____ _____ _ __-__ _______ ------------- -----�___ ____: ____ ___:: _:: __ PERMIT No.�7 Y----- ISSUED-------- --- --7. ...-_____--(Date} FINAL INSPECTION BY:--------------------------------------------------------- Date-------------------------------------------------------------------------------- SAN ------------------------------------------------_-------Date----------------------------------------------------------•--------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639 14