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APPLICATION FOR SANITATION PERMIT y 1 (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. e-2 / �'l cif l^/ _ JOB ADDRESS AND LOCATION____ -------------------------------- Owner's Name--------------- - �1 r3 CT .-- ----- --------------------------------- Phone ------------ Address------------------- l��I ------------------------------- # Contractor's Name___ C3" �L/ ------------------------------- -- - ------------ Phone -------------------------------- --------- -----=---------------------------------------------- - .installation will serve: Residence ❑ Apartment House ❑ Comms e ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: '[� Number of bedrooms � Number of baths ❑ Lot size-_____ ---- ------------------------ Water Supply: Public system Community system ❑ Private ❑ Character of soil to a depth of 3 feet:i Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe [] Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic an k: Distance from nearest well------7-------Distance from foundation___1p_____---__.Material____-_�v��.�� �( � f� N � No. of compartments-------- '-------------Capacifiy____[2_ !7 Size3�C,I_-?�'- Liquid depth-----T----______------ Cesspool: Distance from nearest well-----------------Distance from foundation-------------_------Lining material__-_____________--______ - ❑ Size: Diameter------------ ----------------------Depth---------------------------------------------------- Privy: --------------------------- --------------------- 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___-_---____-__ ■ � . s ❑ Number of pits-------=---=----------Lining material------------`-•-------Srze: Diameter----------------------.Depth--•-------�-------------�---- -Disposal Field: Distance from nearest well___________-____.Distance from foundation_._f�__._________Distance to nearest lot line___________ Number of lines-----_ ___.__Length of each line______--` tf_ ---- y _______.Width of trench__- `P Type of filter material__ fa-Depth of filter material______-_-� `�____ -Remodeling and/or repairing (describe)________________________________ N -------------------------------------------------------------------------------- --------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- ---------------------------------------•---------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stans,�nd rule ndegulationsof 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______________3 r� I DATE REVIEWED BY �' -- � / f� ---------------------- ----------------- ----------------------------------------------------------------------------- DATE------ ---///- ! I DING HERMIT ISSUED. ------- ----- ------ DATEr - ------------------------------------------ ---------- - Alterations and/or recommendations___________________ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------ ----------------------------------------------------------------------------------------------------------•------------------•----------------- -- ------------------------------ - PERMIT No. ISSUED__________ ____e"__(Dafie) FINAL INSPECTION BY:__.._----_ Date s. j1 #----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT � 130 South American Street I ES-9-2M 4-50 W-1639 Stockton, California f'