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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) ALica}ion is hereby.made to the San Joaquin Local HealthdDiNoc for a permit to construct and install the work herein described. pp This application is made in compliance with County r ` Si -Aj! -D i F ------- ----------- JOB ADDRESS AND LOCATION / T7te Phone------------------------------------ Owner's Name--------------- ------------------------- Address --•---- ` -- ----- - ---- -------- ----- - -- --- --- -- ----- ----------- Pone------------------- Contractor's Name--------------------------------• ----- Trailer Court ❑ Motel ❑ Other ❑ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size-"------------------p -- -- Water Supply: Public system ❑ Community system ❑ Priva}e ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay�Loam [I Clay El Adobe[I Hardpan E] ` TYPE OF INSTALLATION AND SPECIFICATIONS: i tank cr cesspool perini#ted if public sewer is available within 200 feet.) No septic p nrCS_---_--"_. Septic ank: Distance from nearest well � Distance fro foundation-___fv-_-_______-Material__._- 1 �,--- t y ----Ca acit �--Q--------Size-� biquid depth-- = ��`�-- . No. of compartments---_-_-"-"1--- p y Cesspool: Distance from nearest well-----------------Distance from-foundation-"_____--"_-__--- .Lining-material-:--`:_--""-------------- Size: Diameter--------=-----------------------------Depth------------------- -------------- ---------------- F1 ------------ Distance from nearest well_-""___________________"----_-------------•----Distance from nearest building_-- -- Privy: i ❑ Distance to nearest lot line--______-_"---_- �_--� Seepage Pit: Distance to.nearest well_-_"=_�--------------Distance from foundation-----------------"-,Distance to nearer} of ine---____"---_�__ -�' --Number of pits- =-----------Lining"n tenal:� _ � ---Size:-Diameter--=-==--------'-------Depth-__ - ` ,..� ❑ , t Distance from foundation_---,_�?__---_--�-Distance to nearest lo`lline - Disposal Field: Distance from nearest well � -___-_. Width of trench-_-Z__-"----------------------- ,d Number of lines_-__-_-_-_- -ii---------t----Length of each line-------a-- f Type of filter material__I�--,rP-i'.'* ---Depth of filter material-_-_ -_- ----------- ------------------ i -60------- �, t _ S .d� _ ,� -'------------- ------------------------- ------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------C I hereby certify that I have prepared this application and +hat +he work will be done in accordance wi+h San Joaquin County ------------------------------------------------ -------------------------------------------- ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. Owner and/or Contractor) Signed) y _' :r?F'2,. `_ ------------------------ l -- Title ----------------------------------------------------------- ----- (Plot pians, showing size of lot, location of system in relation to wells, buildings, etc., must be fled with this application). FOR DEPARTMENT USE ONLY e DATE------- C ------------------------ APPLICATION ACCEPTED BYE_ -- DATE-------------- REVIEWED ----- ---�- /�'j --------------- REVI EW ED BY-------------------- - r.v •� i DATE-------------------------------- UED PERMIT ISSUED----- --------------------------- Alterations and/or recommendations_________________"_ -- -- ------- ---------------- h Ty -- - ---------- - ----------------------------------- ------------------------------ --------------------------- (Date� FINAL INSPECTION BY ----------------- -- - 1 PERMIT No------ -2'------- ISSUED �= �� ~w 3 S SAN JOAQUIN L CAL HEALTH DISTRICT 130 South American Street Stockton, California ES—q-2M 9-50 W:1639 P �.