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f APPLICATION FOR SANITATION PERMIT p' (Complete in Duplicate) A: 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 mina ce�No. 549. E JOB ADDRESS A JD LO,CATI � a- ----------------------------------------------(--------------------------------- e� � / �C� Owner's N me .' ------- 3 �t----------------------------------- Phone�5l Address--- e = ----------- -- -- ---- ----------- -------- = Contractor s Name__________ "; Phone- ------------- ---------------------------------------- Phone will serve: Residence ❑ Apartrnent,,.House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: [] Number of bedrooms ❑ Number of baths ❑ Lot size_ _______________________- -- Water Supply: Public system ❑ Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) A Septic Tank- s Distance from nearest well_________________Distance from foundation___-______________-Material__________________.________-___________-_______." No. of compartments--------------------------Capacity-----------------------Size------ ---------------------Liquid de I ------It---------- ---- Cesspo : Distance from are well*___ __-Distance frQTn foundation------_' _ ___----.Lining material______________ _______ ----. 1) Depth--------lb---------------------------------------- Size: Diameter _ F' Privy: Distance from nearest we}I-------------------------------------------------Distance from nearest building________-__---------_---_________________- t d Distance to nearest lot line________________________________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------------Distance to nearest lot line__-______________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---'_______________.Depth--------------------------------- Disposal Fields.." Distance from .nearest well___� `�'____-Distance from,foundat-ion�-$��_--_"_Distance-#o'Re�res#lot lir ________________ G F. _ Number of lines______________________� _______Length of each line_____ t..........Width of trench___._ _ _________ ------------ Type of filter material___[_ '____Depth of filter material---L0-_____________ f°'�-�1,• _' v mac_ e -- - Remodeling and/or repair't�g (d scribe=------- - -----'- - ---;---- --- ------- ----:------------------- - `�--------- - _ ;�, ,o :. -------------- -- --------- -------------------- ----------------------------------- --------------- 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. .1I � s (Signed) +� P,4_C- -, ------ ------------------------------------------------------------(Owner and/or Contractor) '"----- Title BY:----------------------------------------------------------------- -------( ) -----------------------------------.---- ------- (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-- l REVIEWEDBY------------------------------------------ ----------------------------- -------------------------------------- ------ DATE------ BUILDING PERMIT ISSUED = ---------------------------------------------------------------------- DATE---------- � --------------------------------------- Alterations and/or recommendations:------ ------------------------- --------- ---------------- -- --------------- ----------- ------------------------------------ `� - ---- - �- ---- -- ---_-------- --------- --- ---------------- C�e -------------------------------------- 1 , ,r - -------w- --- /f] IF -----------------/ -------------------------------------------___--------------------------- 1--------------------__---- -------------- --------- ---- -fr�'� - ------ ------------------------------- ' V ------------------------------ p 7 - y V PERMIT No._ 5-.- _-- ISSUED-____ _7_ ----(Date) FINAL INSPECTION BY:-------w___________________ ___________________------ Date--------------------- y SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 4-50 W=1b39 .