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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) 1 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_ D ------ - ---------------- ---- --------------------------------------------------- Owner's Name------ ------- Phone -------------------------------------------------------------- Phone------------------------------------ Address--- --------------------- -- Address--- Q , Contractor's Name___ •---�-- - -�---{�--- ----------------------------------------- Phone--9-- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 0 Number of bedrooms 0 Number of baths 0 Lot size___Z_.T__rx_"I__0__Q!__""""" " Wafer Supply: Public system 1A Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Ej Clay Loam ❑ Clay ❑ Adobeg 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--7"7_____Distance from foundation------f4_1----Material______ XNo. of compartments__,_______ r►""""" ( � Capac�tY � _._..Size__Lr . 4-------Liquid depth--- --------Cesspool: Distance from nearest well_-_---______"-Distance from foundation____________________Lining material____---__-______________________- ❑ Size: Diameter--------------------------------------Depth----------------------- ---------------------------- Privy: Distance from nearest well______________________________ _________Distance from nearest building ❑ Distance to nearest lot line_______________________________________ Sey e Pit: Distance to nearest well____`______________Distance from foundation---Ls.p_�__- Distance to nearest lot line____±r_D""11 Number of pits-------I___________Uning materiaL-Ce-4 Diameter___.'-_'*!-------Depth_-___•,�_p_`.- -----__--- Disposal Field: Distance from nearest well____--_-__.Distance from foundation----IX-'-__-Distance to nearest lot line----/ Number of lines__________ -- ____- ___Length of each line----- of trench___ ra Type of filter material__ __ +-� �,�""�__ _Depth of filter material______,�_�_______. Remodeling and/or repairing (describe):_________-"_________ ----------------"------------------------------------ - ---------------------------------------------------- L ------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------- 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, and rules and regulations of the San Joaquin Local Health District. (Signed)--- - _A"`-----E N - - ,_ I.4-�.-- ------ ---- ------------- ------------iv---------40wner-ara 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_____" t t �I -� j -i- - �. - REVIEWED BY-------------------------- ------------ DATE - - -- ----------------------------------- UILDING PERMIT ISSUED_ ------------- ------ DATE --------------------- ------------------------------------ A+erations and/or recommenda+ions:_____________________ " -------------------------------------------------------------------------------------------------------- ----------------------------------------------------- - ------------------------------------------------------ ------------------------------------------------------------- PERMIT No.J/--p( --------- ISSUED_"_ -d-/__�,4"/---------------(Date) FINAL INSPECTION BY:_---_ Date-------------- . _---"�- ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT — 130 South American Street E5-9-2M 9-50 W=1639 Stockton, California