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APPLICATION FOR SANITATIOw.l PERMIT (� (Complete in Duplicate) Application is hereby made to the San Joaquin Local Health District for a permit to constr-uct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION _ ' -- Owner's Name------- 4:_ ((------- ------- - -- ------------r------------------ -------------------------------------------•------ Address ._ _ t, ------------------------------- :----------- Contractor s Name--------�- -- � -------------------------------------------------- --------------------- Phone----------------------------------- Installatiowill serve: Residence It Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ 2ther ❑ Number of living units: ® Number of bedrooms EQ., Number of baths [M -Lot size--- a' ,__-__ -`. 1---------------- Water Supply: Public system [ Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 10 Hardpan ❑] TYPE OF INSTALLATION AND SPECIFICATIONS: t ' -��l— (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ; t Septic nk: istance from nearest well_ _"'2v___-Distance fr m foundation _ ) - Material lL-------------------------------------- C.7 DNo. of compartments______ Capacity__ __� � V-___Liquid de th_� _0_ _______ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- ElSize: Diameter--------------------------------------Depth---------------------------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ F1 Distance to nearest lot line------------------------------------------------ ` Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- Disposal Field: Distance from nearest well_"-1_D_�_�Distance from foundation____________________ Distance to nearest lot line-4)____,_ Number of lines______________i___ -------- -----Length of each line__________!___- _d-----Width of trench-___--__---2----------_---------_ Type of filter mate rial__/_Y3,--_ o --Depth of filter material------_1�'_�------ -Remodeling and/or repairing (describe):----------?�4 A-------- c "1 {-wt------------ D1--,R f --•---. -•--------------------------------------------- -------------------------------------- ---------------------------------- ----- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County o4nances,-State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) / ' - 1-------------------------------------------------------------------------------------- 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 f APPLICATION ACCEPTED BY ---------------------------------------------------------------------- DATE---- - REVIEWEDBY-------------------------------- --------------------------------------------------------------------- DATE-------- ----------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ '--------------------------- -------- 1 1 h. 7'a [� - +'1 -----8T------?s-------- o F v '_cF___ l CNn or-ferr ------------ s.-- 5-no --- ------------------------------- - -' PERMIT No._-- )_9-------- ISSUED----/._�------- ----------(Date) FINAL INSPECTION BY------------------------`- --/! �. Z7. Date------`-�---- ------- ---------------------d-------------------------•--- SAN JOAQUIN LOCAL HEALTH DISTRICT � �// '000, � £ , 130 South American Street Stockton, California 4 j E6-9-2M 9-50 W=1639