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APPLICATION FOR SANITATION PERMIT 'Pa 0 (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_ _ _________________________________________ Owner's Name -------------- ------,-------------------------------------------------- Phone------------------------------------ Address----------------------------------------------------------------- Contractor's Name-------------- -------------------------------------------------------------------------------------------------------------- Phone---------------------------------- Installation will serve: Residence 0 partmenf House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living unifs: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size_______________________________________________________..._.. Water Supply: Public system ❑ Community system ❑ Private 9�_ r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[3-4t5rdpan ❑ ar 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-------•------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material______---_-_----__-----______________. ❑ Size: Diameter--------------------------------------Depth.--------------------------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ El Distance to nearest lot line------------------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation__________________Distance to nearest lot line----------------- 17 Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth----------------.._.------------- _Disposal Field: Distance from-nearest well___t7D____.Distance from foundafion___.,/--V Distance to nearest lot line__I_�__________ 16, f----- // Number of lines------------ ___ ___Length of each. _=__�1.�-�___ Width of trench_______� � _ ________________ - 'J1 rr----- Type of filter material______ __i!2_f -�h Depth of filter material______)_2---------- 'Remodeling and/or repairing (describe):------------------------- ------------------ ------------ --------------------- ------•------------------•------------------------------------------------ ..-- ----------- ------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------- 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)..--,/ - ---- ------ - - ---------------- -------------------------------------- -------------------------=-----{Owner and/or Contractor) ---- z - - ---- - ---------------------------(Title)--------------------------------------------------------------- ionof - (Plot plans, sh e of lot, locat �sation to a S. uildings, etc., must be filed with this application). ; FOR DEPARTMENT USE ONLY , APPLICATION ACCEPTED BY----------------------- - ----------------------------------------------------- DATE------------------------------------------------------------ REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED---------------------------------- ------------------- --------------------------------------------- DATE-------------------------------------------------------- - Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------1------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------=-------------- ------------------------ ---- -- ----------- -- -- '------------------------------------------ ---------------------------------- ------------------------------------------- PERMIT No.____f ----- ISSUED____-- ---- --P -- _-----(Date) FINAL INSPECTION BY--------- --------------------------------- . � Date--------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639