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APPLICATION FOR SANITATION PERMIT , (Complete in Duplicate) 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install h -wore kh errer describes This on is_made in compliance with County Ordinance No. 549. fir JOBADDRES�AND LOCATION------------ -- --- --------- ------------------------------------------ ------------- -- t Owner's Name_..--- - -- -------------------------------------------------------------------------------- one--------------------------------- Ph .� Address-- � + � � '" v- ---------- ---t -------------------------------------------- Contractor's Name------------ Phone Installation will serve: Residence Apartment House El Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ , Number of living units: [ Number of bedrooms 0 Number f baths 0 Lot ------------------------------------- Water Supply: Public system ❑ Community system ❑ Private Character of soil to a dep;iAof 3 feet: Sand ❑ Gravel ❑ Sandy Loam N Clay Loam ❑ Clay ❑ Adobe ❑ -Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet .J/ Septic Tank: Distance from nearest well----fdl!�Distance from found tion-__1_ __ _____.MPteria!_______r `--___________________ No. of compartments____--_`-----------------Capacity----x-0441_Size_/-.Q __ �!" iquid depth----- '--------------` Cesspool: Distance from nearest well-----------------Distance from foundation----------------- material_____----_____-_____________.-____. .❑ 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: Diamete -----------------------Depth--------------------- T. Dispos Field: Distance from nearest well __S O r__Distance from foundation _ __ -._.Distance to nearest lot �ne___-_� __-. Number of lines-----------------I- --- -Length of each line---------r __u_-__---Width of trench-----�------------------------ Type of filter material_,S'�__� _Depth of filter material------,/ ....... Remodelingand/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. i __________ (Signed)---- �„----------.' U_ �------------- ________(Owner and/or Contractor BY:------------------------------------- -------------------------------------------------------------------------(Title)---------------------------------------------------•--------- ' !I (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). 1 l FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY______________G _______---------------- DATE-------_-- _-- REVIEWED BY----- ---------------- ------- --- ------------------------------------------- pATE. `'` - ------------- a BUILDING PERMIT ISSUED----------------------------------------- DATE : Alterationsand/or recommendations----------------------------------------------------------------------------------------------------------------------_-----------------•------------------- PERMIT No-------- .._. ISSUED--------------- y �� ---(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 3 I