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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 LOCATION--•.--.J3_11---- Owner's --1---Owners Name_ " O" --------- ----------------------------------•-- Phone-----2 -- -3- L3_ -------------- ----- --- -Address-------------- -----P�tp.p' .: 4= Contractor's Name---------------------------------------------------------------------------------------------------------------------------------------------- Phone---------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size_________-----------__________________________________________� Water 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 200 feet.) Septic\Tank: Distance from nearest well________________Distance from foundation-----------:__...._.Material------_;_______-____-__________.----------------- ❑ 1i No. of compartments----------------- --------Capacity-------------------- ,Size.......-------------------------Liquid depth--------------------------- Cesspool\N\ Distance from nearest well___--------------Distance from fou6clat.iRn--------------------Lining material:L__-_______________-._____________- ❑ Size: Diameter-------- % ` \ Depth_ � Privy: Distance from nearest.,well-------------------------------------------------DistanceMrom nearest building--------------- �___________ ❑ \ Distance to nearest lot'li ne------------------------------------------------ F Seepage Pit: ',Distance to nearest well----'\ ------------- from foundation--------------------- to nearest lot line-________________ ❑ Number of pits----------------------Ling material-----------------------Size: Diameterw_____________._____-.Depth---------------L----_----------- Disposal Field: Dilstia nce from nearest well-------\,,__._Distance from foundation___________________~Distance to nearest lot line`,______----. ❑ Number of lines-------------------------------- _____________________________\- Length of each line------------------------------1Nidth of trench----------------------- Type of\f lter material--------------------------- ______________________`Depth of filter material_______.__-____________ Remodeling and/or- repairing (describe):-----------—J_l r,lG ---------- ------- ----------------- --- --------------------------•------ '� w.G ..., _____.__-- _____________f_____ _.__ _Q__________- r ---------------------------_--------------------------------------------------________»__._____________________ ____--_______________________-____-_-_-__------____-_.________._..______.._-_._________---.----__--_________-_ I hereby certify that l have prepared this application and +hat the work will be done in accordance with San Joaquin County ordinances, State laws nd rules and regulations of the San Joaquin Local Health District. (Si ned � y,. g )- "I--••• ` (Owner and/or Contract6r.) "<it BY: --- -------------------- (Title) = a: (Plot plans, showing size of lot, location of sys em in relation to wells, buildings, efc., must be filed with this application). . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------ --------- -- DATE - ' REVIEWED BY. —I,,— `� =------------------------------------------------ DATE------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------------------- Alterations and/or recommendations:--------------------------------------------------------------------- ------------------------------------------------- -•--------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------•------------------- ----------------•---------------- ------------------------------ ----------------------------------•----------------------------------------•----------- ------------------------------------------------------------------------------------------- PERMIT No....a ISSUED----- - ----(Date) FINAL INSPECTION BY:---------------------------------------------------------------- Date--.-----•----------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W4639