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APPLICATION FOR SANITATION PERMIT 4-- (Complete in Duplicate) g Application is hereby made to the San Joaquin Local Health District for a permit to This application is made in compliance with County Ordinance No. 549. construct and,install the work herein described, JOB ADDRESS AND LOCATION_____;x._" 41 ._3._�'_ - t- i ,� Owner's Name--- � � ' "'-" ""-" . -1,� ,t -------------------- --- Address----•--------- 1� ----------------------------- --------------- Phone- z1�'. Contractor's Name_.---------0_"Wtq�-+ � - -------- Installation will serve; a T' p t Residence ❑ A art�ent'House,❑ Commercial " - --- Ph°ne___________"-""-- Number of living units: � Number of bedrooms ❑ Trailer Court [] ;Mofiel ❑ 4 Other C_4 6/iV F Wafer Supply: Publics stem ❑ Number of baths ❑ Lot size_______ Y �� Community system Character of soil to a depth of 3 feet: SandF J ❑ Private ❑ f ❑�Gravel.0._ Sandy Loam ❑ ClayL TYPE OF INSTALLATION AND SPECIFICATIONS:, oam ❑ Clay ❑ Adobe Hardpan E] w (No septic tank or cesspool permitted if public sewer-is available within 200 feet.) , Septic Tan l�: Distance from nearest well:___________ r Distance from foundation-----------------"Maferial ---------------------------------------- Cesspool: _ i5P`"1 No, of compartments____-----"-"---"- ----- -------Capacity----------------- ---Size__-----�------- ---------- --------------------- !� Cess ool: ' =-----Liquid depth-------------- ❑p Distance from nearest well ________Distance from foundation--------------------Lining material Size: Diameter---------------------------------------Depth ---------------------------------------------------- -Privy: ----------------------" - Depth--------------------------------------------------- ._Privy: Distance from nearest well__________-�__--__ � from nearest buildin Distance to nearest lot line_-__""-"_______ t Distance fg_--"_-"-""_ Seepage Pit: Distance to nearest well _________"Distance from foundation _ 4 ❑ Number of pits_____________ - -.Distance to nearest lot line__-________-_- ---------Lining material-----------------------Size: Diameter_------------""--- -- Disposal Field: Distance from nearest well___~� t �. -Depth_____" Distance from foundation------ 01 to nearest lot line------ Number of lines--------"__--- "- __- Length' • Type of filter mat e'ial '- g ;°{ each line:_________ - ► -----------width of trench-------- ~4`+� - _Depfh of filter, material- _ _// Remodeling and/or repairing (describe);-------------- "-" ,� 4 ! - - ° �. -------------------•--------•----- - - --- ------------------------------------------------------------------ ---------------- --- -------------------erti----------------------`------------------------` '-----------------N"---------------------------------------------------------•---'----------------------•--------------•---------------- I hereby certify that I have prepared this applicafion and that the work will be done in accordance with San J-- uin County ordinances, State laws, and rules a d' r`gulefios the San Joaquin Local Health District. q my (Signed)---- ---- --- x BY:------------------- ------------------------------ ------------- - (Owner and/or Contractor) (Plot plans, showing size of lot, location of system in relation to wells, buildings, efc., must be filed with this application).---------------------------------------------(Title) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY___________ __ "_ -- -------------------------------------------------------- REVlEWED BY------------------------------------------------- �f DAT - �"" BUILDING PERMIT ISSUED-----------"_- .. _ DATE--------- - ----------------------- " --- ---------------------- ------------------------------- -•--aerations and/or recommandatians-------------------------- 4 ------ ------------- DATE------�---------------- ----------------------------•----- ------------------------------------ --------------------------------------------------------- ----------------------------- ----------•--------------------•--------------------------- ------------ 1---------------------------------- ---------------------------------------•- -------------------------- -- -------------•----- ---•--- ---------------•------------------------- - PERMIT No....... �� --- r ISSUED_--- _ :ns:ns 1______________(Date) FINAL INSPECTION BY:----^---- Date- !� " AN JOAQUIN LOCAL HEALTH DISTRICT 1. 130 South American Street ES-9-21M 9-50 W-1639 Stockton, California