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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 eCounty Ordinance No. 549. JOB ADDRESS AND LOCATION-------I- nlL{�---�I � - ------------------------ I Owner's Name------------------------ ----------- -- ------------------------- Phone------------------------------------ + Add rens-------------------------------- ---------- ---- --------------------------------- --- -- Contractor's Name-------------------------------------- ------------------------------------------------------=------------------------------- Phone Installation will serve: Residencepartment House ❑ Commercial ❑ Trailer Court ❑ Mote! ❑ Other ❑ Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size______________________________________________________________ Water Supply: Public system Community system ❑ Private ❑ ; Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ ®�# t TYPE OF INSTALLATION AND SPECIFICATIONS: LM (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well _ __ s.A,Distance from foundation----/-Q,d___yater4------ V_�_ No. of compartments_________ ______________Capacity___ -----------Size__ ,t�' ,+(-____Liquid Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- ❑ Size: .Diameter-------1-------------------------------Depth--------------------- ----------------------------- _Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--___________________________________-_. ❑ Distance to nearest lot line________________________________________________ 'Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line---________--___ ❑ Number of pits-----1----------------Lining material-----------------------Size: Diameter------------------------Dept h-------------------------------- Disposal..Field: Distance,from nearest w N:- tE_'Distance f�om'fouridation" __'d 'Distance`ta nearesf lof fine Number of lines____________ ___ ______l_,_,____Length of each line---------- of french---------- Type of filter material--- Depth of filter material--------)_T_......... Remodelingand/or repairing (describe):----------------------------------------------------------------------------------------------------------------------------------------------- -------- --------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------_---- 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. - -1� (Signed)---��ff <- -- r.+fd/. - ----------------------------------------------------------------------------------------------{Owner and/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 r - -------------------------- DATE I 4 REVIEWEDBY--------------------------------------------------------------------------------------------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED----------------=------------------------------------------------ ----------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:-l----------------------------------------------------------------------------------------------------------------------------------------------------------- i ----------------------------------------------------------------=----------------------------------------------------------------------•----------------.---------------------•--*-------------------------------------------- i --------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------- =------------------------ i --------------------------------------------------------------------- --- ----------------- 19 . !-- PERMIT No. r`_ 1------- ISSUED-- ' (Date FINAL INSPECTION BY: Date-------------------- ------------------ ------ I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639