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T T� APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) L ..>�. 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 A OC;ATION _l/ _ IV, -- ------------------------------------------=------------------------------------------------- _ 012. Owners Name- — ame Phone--�------(--- F --- 91 Address----� -------j�� -Con#rector s Name.---�-t-�-f----� �- Phone---.---------------- ------------------ Installation will serve: Residence X ,Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -0 Number of bedrooms IX Number of baths [ Lot size--_k! -- --- _. _ -�.�----- ---------------- Water Supply: Public system ❑ Community system ❑ Private ` Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe)4 Hardpan ❑ 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-----------------Distance from foundation--------------------Material------------------------------------------------- ❑ No. of compartments-------------------------Capacity-----------------------Size----------------•---------------Liquid depth-------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material__----______----_---____.--___.___-_. ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- PrivDistance from nearest well----------------------------------------- Distance from nearest building---_------________-__-------------_----. Y ❑ Distance to nearest lot line------------------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----______-__--__ ❑ Number of pits---=------------------Lining material--.______-__--_--------Size: Diameter----------------------_.Depth------------------------------ r i O �`.{ ----__-Distance to nearest lot line_____ _________ Disposal Field: Distance from nearest well---_�ZP__-.Distance from foundation-_-____ �__ re Number of lines-- Length Length of each lin e........Z_0------ ----Width of trench_-__----�Z.K _________-___-- :Type of filter material_1-?.-_-_ +'Depth of filter.material__-- '- _��_ Remodeling and/or repairing (describe)--------------------------------------------------------------------------- -----------------------.....---------------------- -------------------- - I ------------------•----------------------•---------------- ------------•--------------------------------------------------------------------•----------------------------------------------•------------ ------------- ------ - ------ -- -- ----prepared -------------------------------------------------`--------------------- ----------------------------------------------------•------------------------------ I herebycertify that I have re ared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and' regulations of the San Joaquin Local Health District. (Signed)----�`------------�---------- - ----�------a"'�'---------- ------•-----------------------=----------------- f9poPM/or Contractor) Bn• showing sae o cation of system in relation to (Title)-- -'- - - --- ------------------------------------- (Plot plans, g y ells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------- DATE---------_-_-- -- - r ----- �/ �� ---------------------------------------------- - . --- REVIEWED BY i DATE - --- ------ ---------------- -------------------------------------------------------------- -------------------------------- BUILDINGPERMIT ISSUED-------------------- -------------------------------------- DATE------------ -----------------•------------------------------ Alterations and/or recommendations--------------------------- ---------------------------------- --------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- ----•-------------------------------------------------------- ---------------------------------- ------ ISSUED--I= - '"-S ---------(Date) FINAL INSPECTION BY:---------------Y ---/�'-�- PERMIT No.---�1_ - - - --------------------- Date------ ------------ -� --------------------------•--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639 .y