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APPLICATION FOR SANITATION PERMIT {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 J JOB ADDRESS AND CATION___----- �--/--- - �Q Phone---s..M /'76/9-4--- Owner's Name_ 1 ��--------- f 4- ------------------------- IV Address______________ ___ - --- c :� � �{ Phone- -Q Contractors Name------ will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑i 1 Number of living units: Ft] Number of bedrooms M Number of baths G] Lot size---��-l-'�-_---�---LS ------------------ Water Supply: Public system IX Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand E] Gravel.[] Sandy Loam El Clay Loam El Clay ❑ Adobe 1:1 TYPE E] 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----------------Distance from foundation----------- -____.Lining material-___-------------___----------_-----. ❑ Size: Diameter--------------------------------------Depth--------------------- ----------- ----------------- Privy: Distance from nearest well-------------------------------- -------------Distance from nearest building--------__---_--------____------------ ❑ Distance to nearest lot line--------f-------------------------------------- �p '�' Distance to nearest lot line_--` --_ Seepage Pit: C?lstance to nearest well--(1------- Distance from foundation-- ------Dista� d j � Number of pits--- �lf� -----Lining, 71 :-- ' _Size: Diameter_, _------------Depth_; - ------------------ _.Dispo al Field: Distance from nearest well- .Distance from foundation--------------------Distance to nearest lot line----_-_-____--___ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material _--------------__---- s� ---------------------------------------------------- - Remodelin and/or repairing describe --------------- ------- ------------------'_-----------=--------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------- „�. 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) A-A/ -- ---------- -- -� ---- -- --(Owner and/ Contractor) By:--------- - - - --------'�^�/ -------- - ------------------------(Title)----- ---- io - (Plot plans, showing size of lot, Iota+ion of system in r ion to wells, buil Ings, etc., must be filed h this application]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------------- -- ----------------- ----- DATE--------- ------------------ REVIEWED,BY - . DATE = -------------------------------------- BUILDIN'G PERMIT ISSUED---------------------------------------------------------------- -------------- DATE Alterations and/or recommendations ----- -------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------- - ------------------------------------------------- ---------------------- - -- --------------------------------------- ----- PERMIT No-------- -�Q------ ISSUED-------------------------------- ==--=--- Date) FINAL INSPECTION BY:----- ------------- - --- . Date--------------- ---------- � SAN JOAQUIN LOCAL HEALTH DISTRICT 1.30 South American Street Stockton, California ES-9-2M 9-50 W-1639