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APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinan No. 549. <br /> JOB ADDRESS PaND LOCATION---J---- ----- -- ---- --'----------- - -- _-� <----- <br /> ------------------------------------------ <br /> o __ <br /> Owner's Nam ---- -- ----------- - - --- --- - ---- � - ------------------------------- ------------ - -------------------- Phone -------- <br /> ir <br /> Address----L --- -- - -- --------- ---------- ---'---------------------------------------------------------------------- <br /> Contractor's Name------------------------------------------------------------------------- ---------------------------- Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Traileurs nMtotel ❑ ther El <br /> Number of living units: umber of bedrooms (p Number of baths It Lot size________________-�------ x <br /> Wafer Supply: Publics stem umber <br /> system ❑ Private ❑ <br /> Y Y Y <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ NN <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Se �ank: Distance from nearest well_ ------Distance fr6_ foundation--_1 <br /> Mat al - 4- <br /> 4-,_t------------- <br /> U _____T_____________No. of compartments---------_ _ ____Capacity___ 19_Q_------Size_ _ __x _ t3 <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------ ____.Lining material--------------------------._________ <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- <br /> Privy-. <br /> ----------------------------------------------- -Privy: Distance from nearest well-------------------------------------------------Distance from nearest buifding-_-_-._._..__-___________________________- <br /> ❑ Distance to nearest lot line_______________________________________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line--- <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diame r-_--------------------_.Depth-----__--_--------- -/---` <br /> Dispos Field: Distance from nearest well �'___-Distance from foundation_______ _{___.Distance to nearest lqt I.�ft�______ <br /> [ Number of lines___________.___ _______. k Length of each line__________-_�Q Width of trench______�_'__`_T__._________ <br /> Type of filter material p , <br /> 'C ..F�e th after material________ .___________ <br /> Remodeling and/or repairing (describe)-------------- <br /> ------------------ - - -------------------- -- ---------- <br /> --------------------------•---------------------------­•------------------------ --------- ------------------ ------ - ------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regu[afions'of fhe San Joaquin Local Health District. <br /> i <br /> (Signed) -------------------(Owner and/or Contractor) <br /> 4 <br /> • (Title)_ <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---.---- ------------------------ --- ------------------ DATE___ % <br /> REVIEWEDBY------------------------------------------ ---------------- ---------- DATE--------- .------------------------------------ <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------- ------------------------------------- <br /> Alterations and/or recommendations:.------------------------------------------------------------------------------------------------------------- ---------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------`---,--------------------------------------------------------------------------------------------------------------------------------------- --------- ------------------------------- <br /> PERMIT No--------- _ ____ ISSUED------ --__ _'_________________(Date) FINAL INSPECTION BY--- -_+ ` <br /> Date---------------- {,.� /---------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-1-2M 9-50 W-1639 <br />