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APPLICATION FOR SANITATION PERVIT � (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^ ,!7 Q: ------------------------------------------------------------------------------ Owner's Name---------- -k---- ------------------------ ------------------------------------------------------ Phone---- -1- AddressZ . ---------------------------------------------------------------••----------------------------•---------------••---------------------------••----- Contractor's Name-------------------- ------------ ------------------------------------------ ---------------------------------------- Phone----------------------------------- Installation will serve: Residence j Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: © Number of bedrooms [ Number of baths [4 Lot size----AVK-_�___,��L .�____._--------- Water Supply: Public system ❑ -ommunity system ❑ Private E�,' Character of soil to a depth u. 3 : 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_____________--._--________________-___-______-_- ❑ No. of compartments--------------------------Capacity-----------------------Size--------------------------------Liquid depth--------------------•-•--- Cess ool: Distance from nearest well______/_L�'U__Distance from foundation-_-.______ _ p ) .�----.Lining matenaL�ris.C.�_.,�� 3 Size: Diameter_______3_-_ _� - ----------------------Depth - 3 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__-__.___-___-__. l ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- ` l Disposal Field: Distance from nearest well----1_�_b-----Distance from foundation___��___--_Distance to nearest lot line-----a'-_-____ Number of lines------.-----(----------------------Length of each line__________ ----------Width of trench__- 2-_W_I'___-_---.------ Type ___T e of filter material---r-O_r� Depth of filter material___--- 11 Remodelin and/or repairing describe :------------ F -------------------------------------------------------------•-----------------------------------------------------------------------------------•-------------------------------------------------------------------------•-- ---------------------------------------------------------•---------------•--•----------------------------•---------------- ------------•-----------------------------------------------------•------------------------------- 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)------ ;o-< ------- --------------------------------------------------------------------------------------(Owner and/or Contractor) By:----------------------------------------------------------- ------ ----------------------------------------------------(Title)-------------------------------------------- - - ----- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------V__ ___ _ _____ ____ DATE.____--_-- - J` r-- ------------------------------------- ,� { REVIEWEDBY------------------------------------------------------- -------------------------------- ---- ------ - ---------------- DATE-------- -- / J--- ------------------ BUILDINGPERMIT ISSUED----- -----------------------------------------------------------_------ --------- ----------------- DATE---------------------------------------------------------- - Alterationsand/or recommendations-------------------------------------------------------•-------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------•-•--------------------------------------------•---------------------------------------------------•--------------•----•------------ ------------------------------------------------------------------•---------------------------C------------------------------------------------------------------------------------------------------...................... - -- ------------------------------------------------------------------------------------=------------------- ---------------------•-----------------------------------•---------------------------------------------------- - ---------------------------------------------------------------- / --------------------------------- -•----------------------------------------------------••----------•-•-- PERMIT No3 _4I_--- ISSUED___________ ___ oZ ate) FINAL INSPECTION BY ___ V _____:.__.________________:___________________ �f 7 tj a ... Date - - -------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639