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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 LOCAT ONf _ Z 6 1 Z .5�. 5$& --------------------------------------------------- -Owner's, Name-------- Address---- ---------- -- ----- ---- - --------- ------- ---------- --------------- Phone------------------------------------ -r�---�---{,'--"---•---��---��--�--'- --- _. ' ---------- Contractor's Name--------- (A_-\A—_ ------------------------ Phone-- ----------------------------- Installation will serve: Residence ©`'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E:1 Number of living units: -�Kommun;ty umber of bedrooms , '� Number o{ baths Lot size_____ _�--_--�--t� __ ____Water Supply: Public systems stem ----- Y ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Ciay Loam ❑ Clay ❑ Adobe ® Hardpan ❑ 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____:!!y-----Distance fro foundation______-V I No. of compartments_-___- _ � --------Materal____ --vete- ---------Ca aci --------•-- P tY-- - ---�-- Size-------------------------------- Liquid depth------�_-.----_--___ Cesspool: Distance from nearest well-----------------Distance from foundation ________Lining material____-_____.__--_________- ❑ Size: Diameter--------------------------------------Depth---------------- ----------- rivy: Distance from nearest well _-___-Distance from nearest building ----- ET Distance to nearest lot'line ---------- ------------------------------------ Seepage Pit: Distance to nearest well______--------------- Distance from foundation___________________Distance to nearest lot line________________ ❑ Number of pits______________________Lining material-----------------------S 17e: Diameter-----------------------Depth--------- ------- - ------ I Field: -- DisposaDistance from nearest well__ ---___,Distance from foundation.___ Number of lines_______ _ Len th of each line_____ _ G _ __�__•_-_------Distance to nearest lot line______ --- - g y s---------Width of trench--------�---- Type of filter material_. " k Depth of filter 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) 4 ;.------�= ----------- f� y - - (Owner and/or Contractor) �Y :--:------------------------ - -- ----- _ -----(Title) (Plot pians, showing size of lot, location of s stem in relation to wells, buildings, etc., must be filed with this application). FOR 9EPARTMENT USE ONLY APPLICATION ACCEPTED REVIEWEDBY --------------- ----- ------------------------------- DATE--------------- - - - ---- ---- - ------------------------------------------- DATE BUILDING PERMIT ISSUED------------------------ - ------------------------------------------------------------------------- Alterat'ons and/or recommendations: - - mn ATE --------------------------------------------- ---------- ------------------------------------ ~g ' � ._ _ _____ __________________w________,----------------------------------------------- ----------- - ------------------------------------ - - --------------------- ----- PERMIT No.V-- ---_-_ ISSUED___ ............Date) RNAL INSPECTION BY:___.__ -� Date----------- �- ------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W-1639 Stockton, California