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APPLICATION FOR SANITATION PERMIT I' r (Complete in Duplicate) �J�( OS Application is hereby made to the San Joaquin Local Health District.for a permit to construct and install the work herein described. p� 'No. 549. This application is made m compliance with Count Ordinance JOB ADDRESS AN ------------- WA TION___�------- --------- - Owner's NameV.Z,/a -- ----------- - Phone ---------------------- Address_... t- - ------------------------------------------------------------ . y Contractor's Name---------------------- --. Phone Installation will,serve: Residence i Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ❑ Number of bedrooms MNumber of baths � Lot size--_-_-_T --_�--�- -/---•----------------- Water Supply: Public system ❑ Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay L'am ❑ Clay ❑ Adobe❑ Hardpan TYPE OF INSTALLATION AND SPECIFICATIONS: " (No septic tank or cesspool permitted if public se er is available within 200 feet.) Septic Tank: Distance from nearest well_____Distance from oundation___ ____________ Material. J d depth-_-- No. of compartments-------- _-_-_---Ca acit Sq-- z _ = cesspool: Distance from nearest well-----------------D'ssta'rice from foundation--------------------Lining material._ ___-_-_____________-_____----- ❑ Size. Diameter--------------------------------------Depfh----------------------------------------------------- ► Privy: r Distance from nearest well--------------------- ----------------------------Distance from nearest building_-____________.______--------_-__________- Distance to nearest lot line_______________________'_ _______________-__- g p _ 4 See a e Pit: ______________________ . Distance to nearest well _ ce from foundation--------------------- to nearest lot.line----------------- ;.; ' ❑ Number of pits-----------•----------Lining materil------ ------------------ Size Diameter:--_ Q_gplb Disposal Field: 'Distance from nearest well____ ____:___-Distance -from foundation Distance to nearest lot line___+ -- . 3't Number of lines----------r_�_______________ ____Len th of each line___ ..____ __-_=___�_�__Width of french___��0_- -_____________ # Depth' of filter material___ Type of filter material- p - --------- r ._... Remodeling and/or repairing (describe): ----------- ----------------------------------•-----------------_-------------------=----------------•--------------•------------ r ----------------- -------------------•=-..------•-------=----------------------- -----•----- -----------------------------------------------------------------_-------------- ----- ---------------""---------------'---"-------------------------------'----------- ---�I--"----------------------------------------------------------'----------------------------------------------- -----=------------------------------------------------------------------------------------------- I 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. ----------- Si ned ________________________ (Owner and/or Contractor) ' -- By: I --------•-------------------------------------------------------------------------------------------(Title)--------------------------------------------------------------- L (Plot plans, showing size o o+, location of system in relation to wells, buildings, etc., must be filed with this application). L t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------------------------------------------------------------------------- DATE- REVIEWEDBY--------------------------------------------------------------------------------------------------------------------------- DATE-------------------------------------------------------- BUILDINGPERMIT ISSUED------------•--------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations----------------------------------------------------------------------------------------------------------------------I------------------------------------------ . - ----------------------------------------------------------------------- --=-----•--------------------------------------------•---------------------------------------------------------------------------------------------- ----------------------=----------------- ---------------------------------------------------•-----------•--------------•------------------ ------------------------•----------------------------------------------------------- ------------------------------------------------- ---- - - ------------------------------------------------------------------------------- ------ -----•--•-- ------------ PERMIT No.-A/ ISSUED__ ___`,, 17 _____________(Date) FINAL INSPECTION BY:__ ___ _-__ - ____ ______ --------------- Date----------- -_-_-______-_Date-----------7- _ -----------•-------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT t 130 South American Street Stockton, California ES-9-2M 9-50 W-1639