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APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliancewithCounty Ordinance No. 549. <br /> JOB ADDRESS AND LOC4\TION-------! ------ "``"! K,! !�-c-----j-�-.-.L�- -- –L -------------------------------------------- <br /> Owner's Name-----/C------�-�- --�- -------- ----- ------------- ------ <br /> ---- Phone------------------------------------ <br /> ----------------- -- ------------------------------- <br /> Address �ry "�.ttr ------------------- -------- ---------"-------------------- <br /> --------------------------------------------------- <br /> ''' -r` -------------------- ---------------------- <br /> Installation <br /> ------------- Phone_- r <br /> Contractor's Name----- " �,T�'- � ""-""""""------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-g et <br /> Number of living units: w Number of bedrooms 12. Number of baths Lot size--- Q."x------1-_ .-------------------------- <br /> Water Supply: Public system `s Community system ❑ Private ❑ ( �� <br /> Character of soil to a depth of 3 feet: Sand El Gravel El Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�` Hardpan El `J3 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> -------- Distance from foundation----- --------------- <br /> Septic Tank: Distance from nearest well_____ �, - <br /> .� t'-?__Liquid depth__:_-_-_I____ __ <br /> y.�. No. of compartments----------.�.,..---------Capacity-----��f----------- Size! <br /> Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- <br /> {-] Size: Diameter--------------------------------------Depth--------------- ------------------------------------ <br /> ____---____Distance from nearest building Privy: Distance from nearest well---------------------=------------ - g""---""""""" "---------- <br /> ----------------" <br /> ❑ Distance to nearest lot line--------_---------------------------------------- r <br /> Se epa e Pit: Distance to nearest well_---------------------Distance from founclation___ o-- .Distance to nearest lot line-___�-___-__� <br /> "�' Number of pits-------�------------Lining material!. x----Size: DiameterAA__ _1___________.Depth- .e'!c _ mac_ _-- --- <br /> 1W <br /> -- <br /> Disposal Field: Distance from nearest well-__�`�____Distance from foundation_-,,. D_-____--Distance to nearest lotline______��____ <br /> Number of lines----------- ---------------- Length of each line---------1- �-- ------Width of trench-----�-------------------------- <br /> Type of filter material_� _�_� ----Depth of filter material----E_9--__--_--- <br /> Remodeling and/or repairing (describe):-------------------- --------------------------------------------------- <br /> ----------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> Thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> y � °', + - (e�3er�id/or Contractor) <br /> (Signed) -- Y ------ <br /> t i'�l –rte Titlei►sl� � io-� <br /> -- - -- - - - ------------------ <br /> By:------ -�'-------------•--------=-=---- ' -=---------rte"------------------------- --------- - ----------- � ----'-- �-= "- --- -- ---------------- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY f <br /> --cam/ -- i <br /> ACCEPTED BY----- / : DATE------el ` ----------------- <br /> APPLICATION ----------------- <br /> -- -------------------------------------- <br /> REVIE+NED BY--------------------------------------- ----------- -------------------- ------------------------------ -- <br /> DATE <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------- -- - ------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations------------------------------------- ----------------------------------•----------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------- <br /> PERMIT No.__�_�'_S__-------- ISSUED-----r/rIJe- ------------(Date) FINAL INSPECTION BY:________� "_f - <br /> Date------------- ---------- - ------------------ ---------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9--2M 9-50 W=1639 <br />