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APPLICATION FOR SANITATION PERMIT } (Complete in Duplicate) Application is hereby made to the San Joaquin Local Health ealt cD'Noc for a permit to construct and install the work herein described. Thisapplica#ion is made in compliance`with County Ord k� 9. JOB ADDRESS AND LOCATION-------- - --- - ----- ------- ---- -- ----- ------- -------------------- ---- Phone------------------------------------ Owner s Name_______ ---- --------------------------------- ----------------------- Address. ------------I- --------- -----------------"----------•------- one ------- ph Contractor's Name_ --- --- - -- ---- ---- —------- --------- -- Installation will serve: Residence }'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ n_ Number of baths ❑ Lot size______________________________ i Number of living units: [f Number of bedrooms F1 `•�'1 Water Supply: Public system ❑ Community system ❑ Private ❑ Clay Loam❑ Clay ❑ Adobe❑ Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Y i 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-----------------Capacityt from foundation 5ize___..____--- " Material Liquid depth__------- ❑ No. of com artments_______________ Cess ool: Distance from n ! Bares# well-----------------Distance from foundation--------------------Lining materia.___,-------------------------------- Cesspool: ___ --- p ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------- --•----------------------- ------------------- - . i Privy: Distance from nearest well.___-__ D--'------- ---------------------------Distance from nearest buildin ------ /p ------------------- 1 � Distance to nearest lot line------------ ____ -------------------------- est - Seepage Pit: Distance to nearest well-----__Linin mDateral.e from foundation Diameter____Distance tonearestlot line--_------------- ❑ Number of pits----------------------- g Disposal Field: Distance from nearest well_______- ------Denath of from each 1 ne foundation-_--------------- dth ofttren hnearest lot line----------------- ❑ Number of lines--_________________ __ g Type of filter material__________ _________Depth of filter materia --------•-------- -------- Remodeling and/or repairing describe)-------------------------------------------------------- __ ___--___ /•`/ ------------------------ th --------------------------------------------------------ication----------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------- --- -- - 1 I hereby certify that I rules rr pareduthis al olf the San Joaquin hL cal Health heDistrectn accordance with San Joaquin County ordinances, State laws, and 9 iOwner and/or Contractor ( ig ) --- ✓�� Si ned _ - --------- -- - - ETitle - ---------------------------------------------------------------- By:-------------------------------------------------------------------- --- ---- (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, --------------------------------------------------- DATE , . j" j`- ----------------------- APPLICATION ACCEPTED BY $ - -DATE - --� -�---------------------------------- REVIEWED BY--------------------------------------------------------------- ------------------------------------------ ----- - -------- ------------------------ BUILDING PERMIT ISSUED------------------------------------- --------- - ------------------------------------------------ ----------------- Alterations and/or recommendations:------------------ -------- - ---------_---------------.------------- --------------------- • ---------------------------- ---------- - - ------ ----------------- PERMIT No.-A6? ISSUED__ $]j-----------(Date) FINAL INSPECTION BY:_--"_-- --- � Date---------------------- ---; --------------- -- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 4-50 W-1634