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APPLICATION FOR SANITATION PERMIT ' (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,---- ------ _ �` r Owner's Name. ----------- Phone 9 ------- Address - '� �r�,- j = --------------------------------------------- Contractor's Name----------=------------- -------------------------------------------------- Phone Installation will serve: Residence Apartment House n--I commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms .Number of,bathslit Lot size___,l _d r-' _ - ----------------------- Water Supply: Public system E] Community syst rr—Ejl Private I Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam 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_„�i�+----Distance from four ation_./d-� r,.Materi 1, �� - No. of compartments______ g _ Capacity___�_t'_ :__ size--- �A. - /� �'`- ---•-------- i------•-- -. '��-----.Liquid depth--- cesspool: Distance from nearest weil------_----------Distance from foundation------------------- material_____-______________-__ ----- Size: Diameter Depth:. ----- --------------------------- Privy: Distance from nearest❑ well Distance to nearest lot Zine_ Distance from nearest buildin g------------------------------•----------- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------_-------Distance to nearest lot line____________-____ (� ❑ Number of pits----------------------Lining material-----------------------Size: Diameter Depth -------- Dispos ield: Distance from nearest well___.'s ____.Distance to nearest lot lineI__�____-_____ �{ _�_Distance from foundation of lines----A----- __ Length of each line-._____ _i Width of trench___.__ ��-- 'i --- 9 j-------- -------------------- T e of filter material_,C_r�1 - _ pYpDe th of filter material___-1f_ ______-____ I Remodeling and/or repairing (describe):_____ - --------••--------------------------------------- -------------------------------------------- -----------------------------•------------------------•--------------------------------------------------------------•- hereby certify that I have prepared this application and,.}hat the work will be done in accordance with San Joaquin County ordinances, State laws,,and rules and' regulations of the S v; aquin Local Health District. /. 5i ned c -- -_- '..1- �__________________ .._._____-__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 NPARTMEK USE ONLY APPLICATION ACCEPTED BY------------ - ----- - -- ----------------------------------------------- DATE____ REVIEWED BY.------- -------- DATE -------------------------------- BUILDING PERMIT ISSUED------------------- ------------- DATE ------------------------------ Alterations and/or recommendations_______________________ ----------------- ------------------------••--------•-------=----- -••---------------------•----- •---------------- - _ ----------- PERMIT N '7!6: - ISSUED----------- ______.-.__(Date) FINAL INSPECTION BY:__------------------------------------------------------------ ____________------_--- _- f Date --1 ---� - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639