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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 Ordinan e No. 549. JOB ADDRESS AND LOCATION__5 _ ~'_ _ �_ Owner's Name . - ---------- Phone"- '"_° ° - Address------- 4-------------------- ----------------------------------------- ---------------I-------------------------------------------------------------------------------------------. Contractors Name--- -—.e-- .c_ 4 Phone---•---------------•-------------- Installation will serve: Residence Apartmen+ House ❑ ;Commercial ❑ Trailer Court ❑ Mot j Other ❑ Number of living units: Vommunify umber of bedrooms Lg Number of bafhs ® Lot size___ "" _____________ --------•••------------ - Water Supply: Public system system [_1 Private ❑ Character of soil to a depth of 3 feet: Sand E]. Gravel ❑ Sandy Loam ElClay Loam I-] Clay ElAdobe[Hardpan ❑ 1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 5epti ank: ioewell____ ___________DistancYfr Ff u ation-- iteria -----N . of compartments _ depth-- I LJ� Cesspool: Distance from nearest well-----------------Distance from'fcundationt,.----------------Lining material-_______________________________-----. ❑ Size: Diameter--------------------------------------Depth----) = ---------------------I----------------- Y� Priv Distance from nearest well_____________ _______________� 'r`",____Distance from nearest building___________- _____________-----_____-- v i ___ ❑ 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---------------------` ,""-- Dispos 14 Field: Distance from nearest well__________________Distance from foundation_ __ _ -- .Distance to nearest lot line__ __---_--_ [y Number of lines___._:_.__ Length of each line_-_- l�� Width of trench-------- __,'------------------ Type _________________ T e of filter materi �---1- pth of filter material__________ --------- Remodeling - - e � Remodelingand/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, Stake laws, and rules nd regulations of egan Joaquin Local Health District. (Signed)._ __ �)------- � � ---------------------------------------------------------------------------(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 APPLICATIONACCEPTED BY------------------ -0171C.t_j > ------------------------------------------------------- DATE----------------------------------------------------I-------- REVIEWEDBY-----------------------------------------------------� -----------------------------------------------=----- . DATE--------- �u. $�----------------------- I BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------------------------------------- Alterationsand/or recommendations--------------------------------------------------------- ---------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------- -----------•---------------------------------------------------------------------------------------------------------------------------------•---•-----------------------------_-_._.......----------------------------------- ----------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------- ---- ---------------------•-------...----------------------------------------------------------------------------------------------------------- PERMIT No. _ - --"""-- ISSUED_--- -- -- 5- ---(Date) FINAL INSPECTION BY:--------- _Y` ---------------------------- --- Date----------------- -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton; California ES--9-2M 9-50 W 1639