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APPLICATION FOR SANITATION PERMIT —At 7 Old <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the Work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATb0N__ ------------ <br /> -------------------------------------------------------------------- <br /> Owner's Name------------- -------X ------------- -------------------------------------------- Phone------------------------------------ <br /> ---- ------------- --- --- --- <br /> Address--------------- <br /> Contractor's Name---------------------- --------- ----------- Phone--------------------•--------- <br /> ------------------------------------------------------------------------- <br /> -•--- <br /> Installation will serve: Residence El Aparfment House E] Commercial ts? Trailer Court [:] Motel P Other E] <br /> Number of living units: E] Number of bedrooms E] Number of baths El Lot size------ ------------------ <br /> Water Supply: Public system W Community system [:] Private E] <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam E] Clay E] Adobe : <br /> Hardpan E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------ <br /> 171 No. of compartments--------------------------Capacity-----------------------Size-------------------------------Liquid de th---I---------___________________- � <br /> ❑ <br /> Distance from nearest well----- --------Distance from foundation-______- Lining n-raf eria <br /> Size: Diameter---------- ' th--------------------V <br /> ?L P <br /> Privy: Distance from nearest well_________________________ Distance from nearest building------------------------------------------ <br /> ❑ <br /> uilding----------------------------- <br /> ------------- <br /> El Distance to nearest lot line_______________________________________________ } <br /> Seepage <br /> ine------------------------------------------------ <br /> Seepage Pit: Distance to nearest well-----------------------Distance from foundation--------------------Distance to nearest lot line_________________ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- <br /> iy <br /> -Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line___-____________ <br /> F1 Number of lines-----------------------------------Length of each line------------------------------Width of trench-_--------------------------------- <br /> Type of filter material-------------------------Depth of filter material_______________________ <br /> - <br /> Remodeling and/or repairing (describe):-------------- ---------fo-t------- ------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------­------I--------------------- -----------------------I-------------------------------------------------------------------- <br /> ---------------------------•----------------------- ------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)..__... <br /> ------------ - - <br /> ----- <br /> ----------------------------------------------------------------------------------(Owner and/or Contractor) <br /> By•------------------------------------------------------------------------------------------------------------------------------------(Tif le)-----------------------------------11-------------------------- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------------- ----- ----------------------- -------------- DATE--------- <br /> REVIEWED BY--------------------------------------------------------------- -;V/ . _..J. <br /> ------------------------------------------------------------- DATE--------- -------------------------------------------- <br /> BUILDING PERMIT ISSUED---------------------------------------- <br /> -------------------------------------- ----------------------- DATE <br /> Alterations and/or recommendations:----------------------------------------------------------------------------------- --------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------- --— ------*-------------------------------- <br /> ------------------------------i------ <br /> ------------------------------------------ ---------------------------I---------------------------------------------------------------------------------- --- -------- -- - - <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------/-------- <br /> - <br /> --------------------------------------------- ------------------------------------------------------------------------------------- -------------rv� ------ <br /> PERMIT No._�70L-_O--------- IS SU E D----- ------(Date) FINAL INSPECTION BY:._ _Date------------------ ------------------------------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street A. <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />