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I� APPLICATION FOR SANITATION PERMIT (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. 4 JOB ADDRESS AND LOCATION------ l ---------- - - -------------------------------------------------------------- Owner's Name.... ,�,t '''"C- Phone -- -- � ----- . Address,..... 1`-/if-------- ------------------------------------------------------------------------------ Contractor's Name__. i� * .... - --------�-- ^------------------------------------ Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial VTrailer Court ❑ Motel ❑ Other ❑ Number of living units: F-1Number of bedrooms E] Number of baths ❑ Lot size__________________________________________________________ Water Supply: Public systemCommunity system ❑ Private ❑ Character of soil to a depth of 3 feet:, Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ �_ TYPE OF INSTALLATION AND SPECIFICATIONS: NZ {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---------------------------------------------------- .Privy: Distance from nearest well------------------------------------------------- from nearest building------------------------------------------ El. Distance to nearest lot line ___________________________________ Seepa a Pit: Distance to nearest - --__Distance fromation___=____.Distance to nearest lot line_______ ____ _O Size: Diameter______ _____.Depth___ _'_______________ Number of pits_____,/-------------Lining material i_Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line_____------_--__- ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french------------------------- _- Type -- of filter material-------------------------Depth of filter material_____________._______- a -Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- t ------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- - - - -- -- - - ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinance State laws and rules and regulations of the San Joaquin Local Health District. {Signed -----i- - 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). 3 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------------------------11-S-6 DATE------ ; . ,.� ---------------------- REVIEWED BY------------------------------ - DATE ----------------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- ; Alterations and/or recommendations-------------------•------•-------------------------------------------------------------------------•---------------------------------------------------------- I I f ------------------------------------------------------------------------/--------------------------------------- ------------------------------------------------------------------- -----------------•--------------------- PERMIT No.�-7-- --------- ISSUED------ ------(Date) FINAL INSPECTION BY:-------------- -------------------_------- Dafe------------------------"5------- l f--------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California y ES-9-2M 9-50 W=1639 ' . -