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APPLICATION FOR SANITATION PERMIT '- (Complete in Duplicate) Application is hereby made to the San Joaquin Local Health Dist for a permit to construct and install the work herein described. This application is made in compliance with Counfy Ordinance No. 549. JOB ADDRESS AND LOCATION-------- Owner's Name--------------- -----.-L'p a ---------------- ---- Phone----- 7 Address �`� )._.._ -4_C t_. �. --- �--J ---------------------------------------------------------- -----------------------:-----------------------•---- Contractor's Name----------------------------•--------------------------------------------------------------------------------------------------------------_- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size----------_----------------------------------.-_____-___-__-__-- Water Supply: Public system ❑ Community system E] Privafe ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance fromi nearest well_________________Distance from fou�ation___-___.-__________-Material._____> pCapacity------------------- ,ize--------------------------------Liquid depth-------------------------- ❑ No. of com artmenfs__________________________ 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 lof line________________________________________________ \ Seepage Pit: Distance to nearest well__\ _____________Distance from foundation___________.______.Distance to nearest lot li ------------------ umber _:___________- ❑ �ber of pits---------------------Lining material-----------------------Size: Diiamete�=\-----------------------Depth------------ Disposal Field: Distance from nearest well--------_l-----Distance from foundation----------------- Distance to nearest lot line\_______-__-__ ❑ Number of lines------------------------------ --Length of each line------------------------------Width of trench----------------------------------- r ------_---------=-- ------_--- Type of\filter material______________________\Depth of filter material_______--_----- Remodeling and/or repairing (describe)-------------- _�_ -L_-_-___ d t-------- ----------------- ------------------ - - ------ ---------- ------- ------ - ------------------------------------------------------------------------------------------------------------------------------------------------ -----------------------------------------------hereby certify tha+ I have prepared +his application and that +he work will be done in accordance with San Joaquin County ordinances, State laws nd rules and regulations of the San Joaquin Local Health District. (Signed)__.__._-k --------v. -•--- -�--}-�----�� ---------------{Owner and/or Contractor) By: ---------- �k_ ------------ (Plot plans, showing size of lot, location of sydm in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------------------- ------------- DATE----------- REVIEWED ------- ,REVIEWED BY-------------------------------------------------------------------- ---------------------- DATE------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------•------------------------------------------•------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------- ----------------------------------•---•---------------- ------------------------------------------------------------------------------------------------------------- PERMIT No. ------- ISSUED----f ----(Date) FINAL INSPECTIONBY---------------------------------------------------------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639