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3 4Z) 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 LOCATION---------- _/-_Q�---_------ _,�,,_, � � ---'------------ Address Owner's Name-------- --�-�'_�r��_a.,--�--�a----- _��.�.�t_t .:=-'----- ------------------------------------------------ Phone--------------------------------- --------•-----------------•--- ---�--�-._� �:M��t�-__�_•+-_1L,..._� -------------------------------------------------------------------------•------------- Contractor's Name-----f,--------_ l_____ _ -_��-�_�� - ---------- ----- Phone--------- -------- -------- --------------------- -- ------- - -------------------------- nstallation will serve: Residence [/I Aparfinent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ❑ Number of bedrooms ® Number of bathssize // ❑ (�Lot _____-� �.----- --------------------- Water Supply: Public system Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay \ ❑ Adobe ❑ Hardpan ❑� TYPE OF INSTALLATION AND SPECIFICATIONS: Q (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well-_""'`____---Distance from foundation-------a-------Material------ ---- --- No. of compartments___.________- -----Capacity--- 07�'------Size__._`r��_L� �- X 7--Liquid depth------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------_____-__I Size: Diameter--------------------------------------Depth---------------------------------------------------- Distance ---------- ------ ------------------------------- Privy: Distance from nearest well--------------------------------------------------Distance from nearest buildin g Distance to nearest lot line__________________________ Seepage Pit: Distance to nearest well_________-------------Distan.ce-from foundation-------------------- El _ . .�,-��. Distance to nearest lot line 4 _ a _ Number of pits---------------------Lining material-----------------------Size: Diameter---------------�----�.Depth---------Field: Distance from nearest well-__-__--_.Distance from foundation_____�d_ _-Distance to nearest lot line_____Number of lines___� j ' �p -- J�Length of each line 1.S�kWidth of trench �� Type of filter material_________________ __-__Depth of filter materia_____ ____________ Remodeling 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, andruryules andel regulations of the San Joaquin Local Health District. - (Signed)---='----�--;�- �`!-'--•�---!�'" -------------------------------------------------------------------------------------{Owner and/or Contractor) By:-------•--------------------------- - 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 REVIEWED BY------------------- -------------------------- �+ �------� -- ------------------------------------ DATE BUILDING PERMIT ISSUED-------------------------------------------------------------- -------------------- --------------------- DATE Alterations and/or recommendations__________________________ --------------------•-- PERMIT No------ �------- ISSUED------- ------(Date} FINAL INSPECTION BY:_____ ---------- Date1f SAN JOAQUIN LOCAL HEALTH DISTRICT / 130 South American Street ES-9-2M 9.50 W=1639 Stockton, California