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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) s: 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. /.1�__� = [� JOB ADDRESS AND LOCATION---------1-. d--- --- --- - �8---°f-�-�-�--- c------- --- �+_�--�- "---`-------- ----------------- -- - Owner's Name------------------ '.7� ---- Phone-- - -I �'.- = 41Y1 ---------------- - ;y Address------------------------- ii Contractor's Name ------------------------------------------- Phone_- ._7.�7f� -------- In Installation will serve: Residence A armen y s ❑ p use ❑ Commercial 1K Trailer Court ❑ Motel ❑ Other ❑ 1 Number of living units: ❑. Number of bedrooms ❑ Number of baths ❑ Lot size______________________________________________________________ �•, Water Supply: Public systema Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam El Clay Loam ❑ Clay E] Adobe ❑ Hardpan TYPE.OF INSTALLATION AND SPECIFICATIONS: ,, ,- i (No septic-tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation-------------------Material________------___________________-_--------____- l ❑ 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-------------------------------------------------Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line------------------------------------------------ ,,// / ! Seepage Pit: Distance to nearest well-------- from foundation______?_-____.Dist c, to nearest lotl�.9--1-________ Number ofits_____-____ _ Linin material_0�fd ._X___Size: Diameter___ __ ________.Depth____- -________________________ TA p g Disposal Field: Distance from nearest well------------------ from foundation---------------------Distance to nearest lot line---------------- ❑ Number of lines------------------------------------Length of each line------------------------------Width of trench----------------------------- Type of filter material--------------_------____Depth of filter v `material__------.__-_______,___ -------------- ---------------------------------------------------------------Remodeling and/or repairing (describe)-------- ----- -------------F -------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat6'laws and-r les and egulaticris of the San Joaquin Local Health District. ti (SiSi ned ---.-------------------------------- --�Q ner and/or Contractor) ` gned)-- �f -------(Title--- t By---------------------------------------iz' of location of system in -------------------- ----------- (Title)-- ----------------- (Plot plans, showing size y relation to wells, buildings, etc., must be filed with this application]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - DATE V -- ----------- REVIEWEDBY-------------------------------------- -------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------------- -------------------------------------------------------------- DATE------------------------------------------------------------- IAlterations and/or recommendations---------------- -----------=------------------------------------------------------------------------------- ------------------------=------------------------ --------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- ----- ------------------- ----------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------- PERMIT No.___ a�- -------- ISSUED--- --------(Date) FINAL INSPECTION BY__ ______ ______ Date_ •- /7 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639