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APPLICATION FOR SANITATION PERMIT - J�3 1 (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 --------- ------ ---------- ----------------------------------------------------------------------------- { t � Owner's Name---------j;f �_A------- r-4-------------------------------------------------------------------------- -------------------- Phone-------�� ----------------- Address - -------- Address---------------- l t ------------------------------------------------------ -------------------------- Contractor's Name----b _)qAy. __tom t [ ---i--- kn_M4Phone Installation will serve: Residence IX Apartment House L] Commercial ❑ Trailer Court ❑r Motel ❑ Other ❑ Number of living units: L' . Number of bedrooms ❑ Number of baths ❑ Lot size---- _x---- -_____------------------------- Water Supply: Public system ❑ Community system ❑ Private ❑ �+ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ClayA 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_________________Distance from foundation-------------------.Material-----------------------------------`------------- . ❑ No. of compartments-------------------------Capacity-----------------------Size--------------------------------Liquid depth-------------------------- Cesspool: Distance from nearest well-----6--------Distance from foundation--------------------Lining material_______- ______________________- ❑ Size: Diameter--------------------------------------Dept h---------------------------------------------------- Privy: Distance from nearest well----------,a----------------------------------Distance from nearest building-------S________-_________-----_____- xDistance to,nearestlot line----- --------------------------------------- Seeppaage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearestlot line_____-_________-_ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- v _Disposal Field: Distance from nearest well-----------------Distance from foundation_____---------------Distance to nearest lot line ------Length of-each line------------------------ --_.Width of trench---------------------__ [.� Number of lines---------------------------- -=---------- Type of filter material-____________-_-----_,__Depth of filter material_______________________ 'Remodeling and/or rep in g (desc5ribe�:-------�Q-a-!'�=------�-- Ial------' _ -/a----��----- � �lP_ _e----------------------------- -------- ----------------- --------ayp 4lm. ------ �c5---------------------------------------------------------- - -- ---------------------------------------------------------------------- ----------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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) � 4. gY= -------- - ------- }--------------------------------------------------------------------------(Title) (Plot pla , showing size of l , location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____________________ ___ �` - ----�}_�� ----- -- ------------------------ DATE-------- - ------------ �-� ------------------- REVIEWED ------------------ REVIEWEDBY------------------------------------------------- --------------------------------------------------------------------------- DATE---------------------------------------------------------- PERMITISSUED--------------------------------------------------------------------------------------------------- DATE------------------------------------------------- ----------- Alterationsand/or recommendations:----------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------I-------------------------I-------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------I-------------------- ----------------- f` 7 PERMIT No._�- -------- ISSUED------- A----`FAI---------(Date) FINAL INSPECTION BY: ------- ------------------------ Date--------------------- ----------------------- Date---------------- ----------- ----- ----------------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639