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APPLICATION FOR SANITATION PERMIT r (Complete in Duplicate) Applicafion 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 TION :c_ / �J�t /' r� ��' f Owner's Name-- -- -- ---------- ----- ------------- ------------------ Phone • i Address---//4- 4- ------ -------- --------------------------------------------------------------------------------------------------------------------- a. Contractor's Name__.- __ A----- ------------------- ----- Phone--------------------------------- Installation will serve: Residence Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms Number of baths ] Lot size__ ___ li.------------------------------ i A Water Supply: Public system E] Community system.ElPrivate AIf 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.) �� , Septic Tank: Distance from nearest well-__A0--'__Distance from foundation___-16P__-_-____.Material---- e----�/ ____________ w No. of compartments_________.e-----------Capacity---907_S_I_-------Size__:Y�x--- ---------Liquid depth__-j_;Z____'___"_-___. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------------------------- Size; --------------_-_______._ - Size: Diameter--------------------------------------Depth---------------- Privy: Distance from nearest welf-----------------------------------.-------------Distance from nearest building-----------------------------.-----------. ❑ Distance to nearest lot line-------------_______________-________-______ Seepage Pit: Distance to nearest well___"1,, �;j�'°___Distance from fo dation_. ----- Distance to nearest lot *�' Number of pits____/_--_______Lining material ' _ _ _tf_Size: Diameter___r�^��r_______.Depth....w�__`____________________ 66 ._Die osal Field: Distance from nearest weli__, '_ _Distance from foundation_* _____ r� p Ar___-_-Distance to nearest lot line__�8_______ Number of lines- .-./___ ____.F--------------Length of each line____2S----_-------__.Width of trench___--2_KJ*!___ _.._______-____ Type of filter material__Z __ _� _Dep+h of filter material------ -Remodeling and/or repairing (describe)--------------------------------------------------------------------------------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. (Signed)--- / �---.--------- ------------- -- -- ---------------4---------------------------------- ---- ------ r . or Contractor) .t Ely: --------------------------------------------- (Plot - (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - DATE ----- L REVIEWEDBY---------------------------------- ---------------------------------------------------------- ------------------------ DATE-------- ----------------------------------- BUILDING PERMIT ISSUED----------------------------------------- ----------------------------------------------------- DATE----------------------------------------- Alterations and/or recommendations:------------------------------------------------------------------------------=------------------=-----------------------------------••------------ -------------------------------------------------------------------------------------------------------------------I—--------------"--"------------------------------ ------------------------------- -------------------- ------------------- •-----------------------------------------r--------------------------•-I-------------- ........ ,PERMIT No.-----A%K------- ISSUED----- ----------------(Da+e) FINAL INSPECTION BY:------ _ (' ---- ------ Date--------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California , ES--9'-2M 9-50 W=1639 �'