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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. 544. --------------------------•- JOB ADDRESS AND OCATION.____ ___6--�-� �" ocl � - -- -------- ----- ------------------------ --- Phone------------------------------------ Owner's Name------ - ------------- -- ---- -------- ---------- Address---------------------- Contractor's Name-------------------------------------------------------- - ------- ----------------------------------------------------------------------- Installation will serve: Residence JK Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ [ , Number of baths [� Lot size---- 6_111'r-k-1-2-1------------------------ Z Number of living units: ❑ Number of bedrooms Vater Supply: Public system ❑ Community system X Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam X Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑f� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Q------.Ma�rial ------ Septic Tank: Distance from nearest ---Distance from foundation-._-_,- - � No. of compartments------------ ------Capacity-----------------------Size-------X -- Liquid depth Cesspool: Distance from nearest well__-_---____-Di ante from foundation--------------------Lining material__---_--__-----_-_-_-_-__----------,-- ❑ -------------------------------------- ---------- Size: DiameterDept -----"-------------------- ------------ 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_----__--__._"_ ❑ Number of pits -----Lining rn&e.rial------- -------Size: Diameter-----------------------Depth------------------------------- :___-_.Distance from foundatior~"_-- _ _____--.Distance to nearest lot line---- .-_, . , Disposal Field: Distance from nearest well__...,,._- x Length of each line____---3-_-+0-----------Width of trench---------- of lines------------- ----------- g rf Depth of filter material---- -------- Type of filter material___-_ Remodeling and/or repairing (describe)_----------------_----------------------------------------------------------------- ----------------------------•---------------------- ____ - --------------------------------- ---- --- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin oun ty ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-.-_— -'y`-------------------------------------------------- ------------------------(Owner and/or Contractor) Title (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 1111 11 APPLICATION ACCEPTED BY-_"------------- ---- DATE-------`-- -All ---�---tc_�nl,�: ---------- REVIEWED BY----------------------------------------"------------"----------------------------------------------------"----------------------------- DATE-------- ----------------------- --------------------------- ---- BUILDING PERMIT ISSUED--------------------------------------------------------------- ---- -----------=------- ----------- Alterations and/or recomrnendatians:-_--__--___-_---___-_-_ ---------------- -------------------------------------------------------------------------- ------------------------------------------------------------------- - I 3k --------------------------------------------------(--D---- _____ Date FINAL INSPECTION BY:_--___ --�-------�--A--------------------- PERMIT No.L------ k---- ISSUED ! �� I f Date--------- --------- -" --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9--2M 9-50 W-1639