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� j APPLICATION FOR SANITATION PERMIT S [Complete in Duplicate] Application is hereby made to the San Joaquin Local Health District for a permit to co strut# and install the work herein described. This application is made in compliance with County Ord')a ce No. 549. JOB ADDRESS A L ATI _ -- - -------------------------------r----------- Owner's Name `'�A ----------- Phone------------------------------------ Owner's I_1_,� ---------------------------------------------- = Address-- ------- ------- --------------- - ---- - ----- ------ --------------- Contractor's Name--- ------ -----------------------1------------------------------------ -------- ------------------------------------------ Phone----------------------------------- ,Installation will server Residence �partment House ❑ Commercial ❑ Trailer Court ❑1 Motel El Other El size--- Number of living units: [.Number of bedrooms [� Number o afhs [P Lot ___ ------ ------------------- - lic stem Community system ❑ Private Water Supply: Pub y ❑ Y Y Iter of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ElClay Loam El Clay ❑ Adobe Hardpan E]Chars p S TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet. I j T Ma rial ------------- --------- --- Septic ank: Distance from nearest well-- Distance fr u dation______'____ k�-------Liquid depth---- No. of.compartments------------- — Capacity- Size Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_-___._________---_______________. ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- Privy: -------------------- -----------------------------Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------_..__________-----______Y______- iy ❑ Distance to nearest lot line------------------------------------------------ Seepage Pit: Distance to nearest well______-'_______._____Distance from foundation___________________.Distance to.nearest lot line----------------- t: ❑ Number of pits Lining ateria4 Size: Diameter Depth } I ..Dispos 'Field: Distance from nearest we __&�D-----Distance from foundation__1_0-ft------ _ _�_1--------Distance to nearest lot Number of lines_________ � .y------------- Length of each lineWidth of trench___ ___�_ti� ______.____--_-_ _ __ __L ___-______- Type of filter materia __`_" (t' epth of filter material------------I---------- Remodeling and/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, anjj rules and regulatioris of the San Joaquin Local Health District. , � (Owner and/or Contractor] Si ned 4 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------------------------------------- ------- DATE------- __f _-- --- i DATE----------, 1 ; REVIEWED BY--------------------------------- - BUILDING PERMIT ISSUED f ----- ------------ DATE_ vYI ----------- -------------------------- Alterations and/or recommendations--------------------------------------------------- ---I------------------------------ ------------ -----------A --------------------------- ---- ------------ - }, - ---- WF/ C, - ' -------------------------------------------- ---- ------------------- ----------------------------------------------- 1 � ------------------ -------------------------------------------------------------------- -;---; , ------------------------------------------------- -------------------------- ---- PERMIT No___�� - ----------- ISSUED---- �-5 S -----------(Date) FINAL INSPECTION BY: / Date----------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639