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APPLICATION FOR SANITATION PEK-MIT <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 Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION I� 7 l " ------------------------------------------------------------------------- <br /> Owner's Name___________-k------------ ---------- ------------------------------------------------------_----- Phone...... <br /> _ ____/_- ___ <br /> Address 9.4 <br /> 7=----------- - --------------------------------------------------------------- ---------------- ------ ------------------------------------------------------- <br /> Contractor's Name--------------------1 `-*t—----------- --- ------ -- -- - --------------- <br /> - - -- - <br /> --...---- -------------------------- Phone----------------------------------- <br /> -- - - -- -- - <br /> Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: © Number of bedrooms [I- Number of baths 0 Lot size____ -------------_----_-_ <br /> Water Supply: Public system ❑ -ommunity system ❑ Private E�( <br /> Character of soil to a depth o. 3 Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material--------------------___-_________________-___---. <br /> ❑ No. of compartments--------------------------Capacity-----------------------Size--------------------------------Liquid depth-------------------------- <br /> Cess ool: Distance from nearest well------ from foundation--------__ _ g - , _ 2 <br /> p Size: Diameter------ � '�----Linin matenal__G.�T <br /> tar <br /> Privy: Distance from nearest well ________----------------------------------------Distance from nearest building ----------------------------------------- <br /> F1 Distance to nearest lot line____________________________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation---------- Distance to nearest lot line____-_____._.___ t <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------------Depth--------------------------------- ` <br /> J <br /> Disposal Field: Distance from nearest well----J_$_G-----Distance from foundation___-f--------Distance to nearest lot line_____�------ <br /> P( Number of lines__________l----------------------Length of each line----------- ----------Width of trench-_- -1.(__t' <br /> Type of filter material_-. ______Depth of filter material_____;-411- <br /> Remodeling and/or repairing (describe) --------------------------- <br /> ' 'Q''! --� ---------------- •----•-----•------------------------- <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 regulations of the San Joaquin Local Health District. <br /> y' <br /> (Signed)------ f•/,. tt----------------------------------------------- ------------------------------(Owner and/or Contractor) <br /> By:------------------------------------------------------------------------------------------------------------------------------------(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 /> ---------------------------- - ------ <br /> . ___ <br /> REVIEWED BY. - ------------------------------------------------__ ---- DATE .'/ - ------------------------ <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------- ----- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations-----------------------------------------------------------------------------------------------------------------------------------------------------------•- <br /> ---------------------------------------------------------------------------------------------C---------------------- <br /> ------------- - - -------------------------------------------------��LS_ <br /> - - - ------------------------------------•-------------------------.-----------------------------------------------_---------------------------------------- <br /> --------- ---- ----------------------------------------- -------- ----••-------•---•-- <br /> PERMIT Node- ___I____ ISSUED--------- ate) FINAL INSPECTION BY:__ -------------------------- <br /> ___l__ <br /> --------------- <br /> / _Date--------- j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />