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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 applicationis madV_eie inFcompliance with County Ordinance No. 549. AF O DD ESS/hAND LOCATION--- ---------- l�~-- __ -_ -- Owner's Name -- ------------------- Phone----------------- Address----------------------�-`-- =�--•--------------------------- - ------------------------------------------------------------------------------------------ Contractor's Name---------- ( `�' ``[,� �l Phone ------------------------ -------------------------------------------------------- ------------ Installation will serve: Residence ❑ Apartment House ❑ Commercial Ej Trailer Court ❑ Motel ❑ Other Number of living units: Number of bedrooms j Number of baths d Lot size_____________- ~� w -•----------------- Wafer Supply: Public system ❑ Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel [❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if public sewer is available within 2D0 feet.) Septic Tank: Distance from nearest well___,:�Io----Distance from foundation_--_to---------Material �Lr No. of compartments----------- Capacity Sizey�X �o -------------------------- Cesspool: � --- - -------:-- -------- Cesspool: .. Distance from nearest well_________________Distance from foundation-------------------.Lining 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: Diameter-----------------------Depth------------------,--------- Dis os Field: Distance from nearest well-_��____.Distance from foundation____�,./------Distance to nearest lot line-___ _,___ s1� 4'` Number of lines-------'_Y_------- Length of each line---------?o-n----------Width of french-----=---�{- ------_ Type of filter material-__________ -__Depth of filter material______:_ Remodeling and/or repairing (describe):---I--------------- ---------------------------------------- ---------------------- --------------------_-----------------_------------_,.-------------------------------------------- Y -----------------------_---------------------------------------------_------------------------------------------------------------------------------------------------------------------------------- _______________________________________________________________________________________________________________________________________________________________________________________________________..____._______________I k 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)--- --- -----------------(Owner and/or Contractor) - -- -- --------- -- - By -11 t_" ..... Plot fans, -___ size of lot, lots+ion of system in rel -----------------------------------------(Title)---------------------------------------------------------------- ( P g y relation to wells, buildings, efc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------- _ DATE------------- �. REVIEWEDBY ------------------------------------------------------- -------------------------------------------------------- DATE------ ------ -- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE -------------- Aterations and/or recommendations------------------------------------------------------;------------------------------------------- `1 ----------- _ c 1`� ----- =-- ------=-----jr------O� :�sv ----------------------------------- �_� �:= ----------------------------------------------------------- ----------------------------------------------•-------------------- ------------------------------------------------------------ J PERMIT No.__3_&Z------------ ISSUED________2'___L9_-_S �____----_--(Datel FINAL INSPECTION BY:_-: - Date------------ ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2 M 9-50 W=1639