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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Application is hereby made fo the San Joaquin Local Health District for a permit to construct and This application is made in compliance with County diva ' No, 549. install the work herein described. o JOB ADDRESSD � •� CA )ON �_�ir c3 r ------ ---------------- Owner'sName-.-_r_ ---- ----- --- - -------- ----------------------------- ------ Address --------1 ----------------------------- ------ ---------- ---------- Phone__ ------ f; Contractor's Name---___-_ �f ' I --------- Installation will serve: Residence -----------_ -.------ -------------------------------------- --- - ----- Phone---- ----'----------- I❑ Apartment House ❑ Commercial �# Number of living units:'1m Number of bedrooms ❑ Trailer Court ❑ ,,'IMotel ❑ Other @'4 Water Supply: Publics stem Number of baths ® Lot size__- _`' �C /p�_�j - Y ❑ Community system �� ❑ Private � -- -------------------g__— of soil to a depth of:3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay LoamCla "�- TYPE OF INSTALLATION AND SPECIFICATIONS: ❑ y❑ Adobe-lHardpen ❑ � (No septic tank or cesspool permitted if public sewer is available within 200 feet.) tic Sepank: r � Distance from nearest weft----_[' ___Distance from oundation__ No, of compartments----__-_-- ----I� aterial_11"LILJ Q - i/ ------Ca acit Cess ool: Capacity--. X- �Ges Liquid depth-------------------------- p Distance from nearest well-----------------Distance from foundation__-_____-_____-__.Lining material_____________________ ❑ Size: Diameter-------------------------------------- Depth----------------------------- Priv ---- ----------- ❑Y Distance from nearest well_. ------------ ----------------------- Distance to nearest lot line------------- --------Distance from nearest building Seepage Pit: ------------- :Distance to nearest well -----Distance from foundation--------------------Distance to nearest lot line ____________ � Number of pits____.______ - ----Lining material__________________ __ Size: Diameter______-___-_ Dis osal Field: ---- p Distance from nearest we11 --------------------------------- -----------------Distance from foundation_________-_________Distance tonearestlot line________._____.._ <' Number of fines---•-------------------------------Length of each line----------------------------- Type of filter materialDepth of filter material----------_- Width of trench----------------- -- - -- ReVdeling and/or repairing (describe):_____________________ --------------------------- ---------------------------- r y certify ------that I have prepared this application and that the work will be done in accordance with -----------------------------------------•-------------------------------------------------------------- ------ hereby cer#ify +hat San Joaquin Coun ordinances }e I , and ules and regulations of the San Joaquin Local Health District. (Signed)_---' s --- ---• ------------------------------------------------------------- BY--------------------------- --------------------------- ------------------------------------------ (Owner nd/or Contractor) -- -----------------------•---(Title)-------------1 {Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----j..:_______ .k ` ► ----------------------------------------------------------------- DATE---------- l . REVIEWED BY---------------•-------- ---------=--------, �-��----- �i;---------�-_--�- - '` --------------------------------------------------------------------------------- 1LDING PERMIT ISSUED - DATE -------------------------- --------------------------- -- -----• DATE------------------------------------------------------------- ---------------------------------- and/or recommendations____________________________ _---____---------------_------__--- --------- -- -------------------------- ----------------------------------------------------------------- ---------•----•--•---------------- ------------'----------------------------------------------------f PERMIT No------------------------ ISSUED-° -_L- -, �-----(Date) FINAL INSPECTION BY: - -------- Date -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W=1539 , Stockton, California