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APPLICATION FOR SANITATION PERMIT ` . i (Complete in Duplicate) I f �� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descri ed. This application is made in compliance with County Ordinance No. 549. " ----•----------------------------------- JOB'ADDRESS AND LOCATION------- ---.S - -------------------------- � -T Owner's Name--------- --•---------------------------------------------------- Phone------------------------------ I ` --------------------------- Phone------------------------- -------- Contractor's Name----------- Installation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑' Other ❑ Number of living units: [jJ Number of bedrooms jam. Number of baths Q of size---------- -_ - ---a---------------------- Water Supply: Public system ❑ Community system 11 Private ❑ Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay F1Adobe ❑ ardpan, t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well D pistance from found4T -,7 • n___,C__p__ �M`}terial------Lj?te__ e_ _!Q_ ,CJ No. of compartments--------------------------Capacity_ ,� 404Liquid depth-------- -- -_r_ _ Cesspool: Distance from nearest well________________Distance. from foundation--------------------Lining material-__________-----________________'___. f * ❑ Size: Diameter--------------------- ------Depth------------------------------------------- -------- *' r .Priv Distance from nearest well__-'�.......... from nearest building__-_------------.----_------------------. Y� ' ' ❑ Distance to nearest lot line_:_.___;,:_�____________________________ r _ . Seepage Pit: Dis#ante to nearest well________`__._"___.___,Distance from foundation__________________.Distance to nearest lot line_______________ ti ❑ Number of pits------------- ---- Lining material-----------------------Size: Diameter------------------------Depth ----•--.-_- �'wDisposal Field: �Dis}ance-from'-nearest well _. : istance" r6mTfound iori_"`��:9- 1--Widfh Disfance to nearest �7 _7191L_ _1�� T - 1 '}/� &__Q- of trenh______Number of lines__________________ ______ ___ ___L'en th of each line_______ ___•. g ' Type-of filter materia!'_____-'=-` =_Depth of filter material____— --------- Remodeling and/or repairing describe) - __. ----------•1----------- --- ----=-=-� '. ------------------------------------------ ----------------------------------------------------•----------------------- "` ------------------------------------ ------------ ------------ --------------------`---------------------------------------------------------------------------------------- I hereby certify that I have prepared this,application and that the work will be done in accordance with San Joaquin County ordinances, S e aw „and rules ain egula ' ns df the San Joaquin Local Health District, t (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 APPLICATIONACCEPTED BY-------- ------------------- --------------------------------------- DATE-- ----------- ------ -----`�------- ----------- REVIEWED BY----------------------------------------------------------------------- --------- ---------------------------------------- DATE------------------------------------------------------------ - BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE---------------------------------------=-------------------- E Alterations and/or recommendations----------------- ------------------------------------------------------------------------------------------------------------------------------ - ------------ --------------------------------I-------------------------------------------------I--------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------- ----------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- ---•-------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- - PERMIT NO._____-_--Ili------ ISSUED___-I_'�-�---._____�.-----------(Date) FINAL INSPECTION BY:--------- Date--------------------- f--- J _ N---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California E5-9--2M 9-50 W-1639 '"4