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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Ii . II 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 OCATION-_-1Owner's Name_---••------------------- " P. LA-sous Address------------3 / - --------------------=- - --- I: Contractor's Name �r`.?�V -------------------- ---------- - Phone - - Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ' Number of living units: -❑ Number of bedrooms ❑ Number of Lot-size-----------S-�xo ----- - --------------- Water Supply: Public system Community system E] Private E] Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam Clay Loam ` Y � y ❑ Clay (� Adol?e� Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: - ' •- - --�.� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) from nearest Sepfic Tank: Distance Distance from foundation-----/Q_t_6Material_ I_____-_____Capacity---- No.-of compartments_:_______ Size__-____�'C........ �q udpth----_---_-_-_----C- j �4 Cesspool: Distance from nearest well-----------------Distance.from foundation--------------------Lining material____ ______________ ` ❑ - Size: Diameter--------------------------------------Depth------------------------------------------ ---------- Privy: Distance from nearest well______________________ -------------------_Distance from nearest building ❑ Distance to nearest lot line______________________________________________ _ Seepage Pit: Distance to nearest well----------------- -----Distance from foundation--------.-----------Distance to nearest lot line----------------- El Number of pits------------s-- ----Lining material-----------------------Size: Diameter------------------------Depth--(l---------------- -.._ Disposal Field: Distance from nearest well from foundation �l -I f1J� _ _____Distance to nearest lot I�ne________________- Number of lines--------------- _----_ -----------Length of each line--------- - ---------Width of trench--------- -=r-_- '=- Type of filter mate ria l_.jy_'-_Depth of filter material------4�______-_-__ I Remodeling and/or repairing describe)---------------------------------------------•-------------------------------------------------- ------------------------------------------------------------- *' =-----------•------------------------- --------------------------------------------------------------------------------------- ------------------- 1 ----------------------------------+---------------------•--------------- - = - ----------------------------- 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, andr es and regulations of the San Joaquin Local Health District, i K p { I (Signed) f --• ----- -------------------------------- -- --------------------------- ------------(Owner and/or Contractor) . - BY ---------------------------------•------- --------------------------------------------------------------- ----------------------(Title)--------------------------------r----------------------- ---- r (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). ` FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------•------ DATE ; --------- -- �`7`� - REVIEWED BY ------------------- ------ - - DATE - ------------------ UlLD1NG PERMIT ISSUED ---- - ----- DATE----------------------- ---------------------------------------------------------- -------------------------------- Alterations and/or recommendations____________________ ---------------------------- --------------------------•-------•-•-----------•-•-------•--------- - I ••-----------•----------------------------------------------------------------------------------------------------------•------------------•--------------------- ------------------ ---------------------------------------------------------- -------------------------- 4- ----------------------------------------•-----------------------•----------. -•------------ --- ---- ----- - ------------------------- -• --- (Date) FINAL INSPECTION BY PERMIT ISSUED__-- ----------- --------------- - ----- No._-�_��-' __-�� _-•� � - Date---------------------4 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street I Stockton, California i� ES-9-2M 9-50 W=1639 - y II