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T 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. d-V� ------------------------------------- JOB ADDRESS AND LOCATION----------- �l N� GIS 1 Phone------------------------------------ Owner's Name------------------ =Address ---------------- -------------- ��- . --------- • -------------- -------------------------------------- --..---------- � W- _, Contractor's 'Name-------• ---------- Phone ---- -- --- - ---------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [❑ Number of living units: . Number of bedrooms a Number of baths [6 Lot size-----____________________________ Water Supply: Public system [Community system ❑ Private ❑ _4 depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ —Adobe[Hardpan Character of soil to a dep ❑ e TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 200 feet.), _Se tic Tank: Distance from nearest well----- �------Distance from foundation___��_____-_�___.Material _____-� `--- s ------- ------- & _-Li uid depth ----------- r No. of compartments.------ ---------- Ccit ��pSize Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____-_-______________-_______ v ❑ Size: Diameter------•-------------------------------Depth---------------------------------------------------- - $ _____Distancerom nearest building� Privy: Distance from nearest well-------------------------------------------- 9 -------------- ---------------------- ( ❑ Distance to nearest lot line__________________________________ __________ I Seepage Pit: Distance to nearest well---------------------- from foundation-------------------.Distance to nearest lot line----------------- ❑ Number of pits Lining material-----------------------Size: Diameter------------------------Depth--------------------------- ---- I Disposal Field: Distance from nearest well--____________--Distance from foundatio - /'0 Distance line----.Width of french---------7 n_JType -------------------- Type of filter material---� ___�-- epth of filter material___ g_-__-_:___ Remodeling and/or repairing (describe):------------------------------- ------------- --------------------------------------------•-----•-- ------------------------------------ ' ------•---------------------------------•------------------------------------------------------ I --------------------------------------------------------------------- ---------•----------------`--------------- --------------- '----------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and thaf the work will be done in accordance with San Joaquin County ordinances, Staf ws,end rules and regulations of the San Joaquin cal Health District. fi (Signed)Z... -- ---------------------- ----------------(Owner and/or Contractor) -- -------- ------------------------------------- Title ----------- (Plot pla s, showing size of lot, location of system in relation to wells, buildings, efc., must be filed with this application). i i FOR DEPARTMENT USE ONLY i DATE -1-----/ -------------------------- APPLICATION ACCEPTED BY----_-______-------------- ---- REVIEWED BY_ ----------------------------- DATE ------------------ BUILDING PERMIT ISSUED--------------------------- --- DATE Alterations and/or recommendations:-------•----------------- -------------•---------------------------------------------------------------------------- ------------•----------•-----------------------------------------------------------------------•----------------- -- ---------- -- ----------------------------------------- PERMIT No.__ 47!'--- ISSUED.!___LL 5L1•r`-------------(Date) FINAL INSPECTION BY:--------`--------------------------------------- Date.------------------- -•-------------_.Date--------------------'�.r-1 R -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9--2M 9-50 W=109