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{ • � Ud 3 APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Application is 7F,; ereby 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 J �Ix Owners Name ----------------------------------------------------------------- Phone------------------------ . f Address 4 `` ` _�, 't-�xa ------------ - g'-�---- ----------------------- -- - -- ---- - ------- Contractor's-Name - -------------------------------------- - ------------------------------------- Phone----------------------------------` Installation will serve: Residence F�? Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms 0 Number of baths q Lot ` size--- 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 fip -TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) , . Septic Tank: Distance from nearest well -!� ' 1]istance from foundation ___ _____ _.Maferial_0 +C _ _ - -------------- No. -_------No. of compartments___________ - Capacity Size_ ____________-- Liquid depth Cesspool: Distance mnearest well_- ----- __ Distance from foundation--------------------Lining material------------------------------------- El BD _D ------------ ,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 _--- ------- - Number of pits-----------_----------Lining material-----------------------Size: Diameter_____________--________.Depth_________-_________ _ ---------- p _- 4 Distance from foundation____- t --- - Dis osal field: Distance from neares#rveli_� ' "�-� _ �-- � � Distance to-nearest lot•line-_____-�/ -r Number of lines--------------- ` _--- --ii--Length of each line----------U_0---------With of trench-------------- of filter material__!_-...........------Depth of filter i -Remodeling and/or repairing (describe)*-----------------------------------------------=------ -1----------------------------------------------------------------- --_1----------------------------------------------------------------- ---------------------------------�---•------- ' - --_ f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 4 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District, (fined)----- ` (Owner and/o_Contractor) I I/ mfr.• By____________________________________________________________________________--_--________________________-_-______________________(ritle)____._____c2 ��_y_�____ __________-___. (Plot plans, showing size of lot, location of system in relation to wells, build ings,,,etc.,_must.be.filed,withthis-application).�� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------- -- �--- ------ DATE---- -- -------------------------- -- - - REVIEWED BY - - DATE---- -------------------------------------------------- ----------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE--------------------- ---------------------- Alterations and/or recommendations:- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- ----------- ------------------------------------------------------------------------------------------------------------•------- •--------------------------------- --------- --------------------------------------------------------------------------------------------------- ----- --------------- ------------------------------------------------'---- ------------ ------------ �,��, PERMIT No.__,;_H_3-______ ISSUED___ __ ._ _-�- ----------(Date) FINAL INSPECTION BY_______ ______ ----_____________ / 7 5� Date-----------/--- -------- -- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-5U W=1639 Stockton, California R r "