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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. - JOB ADDRESS AND LOCAT.ION-"""___ 3.3 f /Ja& f4= 4_0 , ----- - �_ d----- P ------------------------------------------------- Owner's -- -------------------------------------- Owner's Name---------------------- # -------------------------------------------- Phone---------------------------•-------- � ---- Address-------------------------------• "" iR/ - Contractor's Name----------------------- -'-------------------------_= ' ------------------------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: '❑ Number of bedrooms Number of baths 0 Lot size----------- _4_X!U Wafer Supply: Public system Community system ❑_°Private L] ' Y! v Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ W TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic ank: Distance from nearest well-------____Distance from foundation------- d ------Material___ --------Capacity--. 4_;t No, of compartments------------ "___- ?��-- qdepth-------------- CessDistance from nearest well-----------------Distance from foundation---------------------Lining material--_-------------__----------_-----__-. ❑ Size: Diameter---"----------------------------------Depth---------------------------- ---------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ El Distance to nearest lot line--------------------------_____________________ y Seepage Pit: Dis+ante to nearest well----------------------Distance from foundation_"""""_""-______--_Distance to nearest lot line----------------- I ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- Dis os Field: Distance from nearest well__ R—Distan rom foundation -_t0_ _-_--Distance to nearest lot line--__-S�6 Number of lines------"" - --------------Leng°�each line------� Q '► �" ------------Width of trench--------- d -------- Type of filter material--•-?—.. Depth of filter material--------�r_//----_- Remodeling and/or repairing (describe):-"------------------------------------------------•-------------------•----------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ----------`--------------------------------- ------------------------------------------------ ------------------------------------------- ". hereby certify that I have prepared Phis application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of fhe an Joaquin Local Health District, (Signed)--- --- �+ _.. f {f ' _----------(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 APPLICATION ACCEPTED BY--------------------- ------------------------------------------------------------- DATE----------,---- REVIEWEDBY--------- '--------------------= ----- ------------------------------ ---------------------------------- DATEj ------ --- ------------------ BUILDING PERMIT ISSUED -------------------------------------------------------------------------------- DATE Alterations and/or recommendations:-----"---------------------------------------------------------------------------------------- -------------------------------------------------------- --------------------------------------------------------------------•--------------------------------------------------------------------------------------------- --------------------------------------------- -------•---------------------------- ---------------------------r--------•--------------------•--------------------- - PERMIT No.__ AIA----_ ISSUED-_.D,-_�-�Y l (Date) FINAL INSPECTION BY:- m s --------------------------- Date-------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W=1639 Stockton, California