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' APPLICATION FOR SANITATION PERMIT f (Complete in Duplicate) Application is hereby made to the San Joaquin'Loca! Health District for a ermit to construct and install the work herein described. This application is made in compliance with County Ordinance No, 549. JOB ADDRESS AND L W ATION______ , Owner's Name.------- = h - ------------------ -------- ---------------------------------------------- -'- P one - - Address------- -- -------- -- - - .- ------------------------------------------------------- :------ Contractor's Name-----___ -------------------------------------------- -------- Phone,__A � . ,Installation will serve: silence e Apartment House ❑ Commercial ❑ Trailer Court El Motel F-, :Other Number of living units; Number of bedrooms [ ] Number of baths V Lot size_-___ _ilcel ' ---- - ---- ------------------- Water Supply: Public system Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ir Hardpan V TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank- Distance from nearest well---- -----Distance fro foundation___ -`— 1e ;al--- - - -- ------ ----No. of compartments---- ? CZLiq id depth----- ---- ---- Cesspool: Distance from nearest well-----------------Distance from foundation__________________ _Lining material____ El Size: Diameter--------------------------------------Dep ----------------------------------------------------- .Priv "'" th .,• . y Distance from nearest well______________________ Di El Distance to nearest lot line________ stance from nearest building _______ _______________ -- See age Pit: Distance to nearest well__+___-------_________Dista e r m ation____ `_____-.Distance to nearest lot ne:�______- Number ofipits_____-"/____________Linin mate ial" ` Lining -S----Sze: Di-amete�}: --- -----Depth Dis osal Field: Distance from nearest well________-_ _ __.Dista from f dation-_________________,Distance to nearest lo�__ Number of lines___________ - Len th of each line____- 7 /-� -- g .--��-----------------Width of trench___ Type of filter materiel __ �� " _ _____Depth of filter material__-- _-----___" Remodeling and/or repairing (describe)________________ ---------------------------------------------------------------------------------- - -------------------------------------------- ------------------------------------------------------------- -- ---------------rk------------------------------- ---- ----- - -- --- ------------------- ------ ---- I hereby certify that I have prepared this application and that the wo .will be done in accor- - -d-ance-- --w-i-th San Joaqu- -- in Coun--ty ordinances, Stat s, an r les nd regulations of the San Joaquin Local Health District. (Signed)------------ - -- .. ( - -- -- -- ------- - - - -- By: `----- ------ _ ------------------(Title)----�� _Owner /or Co actor] tr (Plot plans, sho ng size o ot, loc i o syste in relation to welts, buildings, etc., must be filed with this application). , FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------i__"---- --t----- '` DATE A7- - ---c - :---------` EVIEWED BY- -----------------------'------------- ------------- -- ---------------------- RBU -------- DATE = fLDING PERMIT ISSUED------ --------------------------- -------- - --------- ---------------------- ---------- DATE---- --------- -- --------- - - ---------------- Alterations and/or recommendations__________________-.__-_---__-"_-_ ------------------------------------------------------- ------------------------------------------------------- ) ------------------------------------ PERMIT No------------------------- ISSUED-------------------------------------------(Date) FINAL INSPECTION BY:s__-_ -- _ --- --- ------------- Date � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street E5-9-2M 9-50 W=1639 Stockton, California