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l _ _ APPLICATION FOR SANITATION PERMIT ` (Complete in Duplicate) f { 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 Cou ty O�dinance. No. 549. JOB ADDRESS AND LOCATION-A--- — .1- ------ Owner's Name - --- --- ------------- Phone f " = j Address----- ---"--d--- ---- Contractor's Name-- � --- -- r� Phone-_ ________!____.,___L�___ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Courtj❑! MTel ❑ Other ❑ 1 Number of living units: Number of bedrooms [;, Number of baths [t Lot size--- __ __i_ _.......................... Water Supply. Public system [Community system ❑ Private ❑ `} 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 i ubllA5e er is available within 200 feet..) Septic ank: Distance from nearest well-- _ istance f f uncle,ion____. .f[_____ .Mater al--- ____ -------------- -- - _______. No, of compartments____________ ___ ________Capacityr jjSize_ _._. - --Liquid depth_______ ______________ - Ee Cesspool: Distance from nearest well-----------------Distance from fbGndation--------------------Lining material_________________________________-_- [� Size: Diameter--------=-----------------------------Depth---------------------------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_________________________-_--__________- Q ❑ Distance to nearest lot line------------------------------------------------ Seepage Pit: Distance to nearest well---------------------Distance from foundation-------------------Distance to nearest lot line__________-_____ ('n ❑ Number of pits----------------- ---Lining aterial-----------------------Size: Diameter------------------------Depth--------------------------�- Disposal Field! Distance from nearest we -_____ Distance from foundation_ Z► I-_ ___Distance to nearest lot lifter______________ + Number of lines----------�__ _-___ ____Length of each line___-_0_�Q__ Width of trench__________________________________ Type of filter materiO_____ ___Depth of filter materia4________;�_ ______ Remodeling and/or repairing (describe)______________________________ ----- - 1 ------------------------------------------------------ -------------------------------------------------- --- -----•-------------------------------- - ------------------ ----------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 44 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, and rues a d re-�ulafions of the San Joaquin Local Health District. V) (Signed)_._.._"-. bL (Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR QfPARTMENT USE ONLY APPLICATION ACCEPTED BY___ --------------------------------------------------------------------------- DATE- - _ , �'----- ---------------------------------------- REVIEWED BY ------- ------------ -------------=----------- DATE' -- ---------- -- --------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------- DATE------ --- --- ---------------------- -----------••--------------------------------- Alterationsand/or recommendations:-------------------------------------------------------------------------------------------------------------------------------••----------•------------------- I ------------------•-------------------------------------- ------------------------- -------------------------------------------------------------------------------------------=--------------------------------------------- ---------------------------------------------------------------•-----------------------------•---------...------------••-------------- --------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- ------------------------------------------------------------- - •-----------------------------------------•--------------------------------------------------------- ------ 1 � -------- ------------------------- PERMIT N __[-_�'___7__-_ ISSUED________ -��__ .._S_.��[Date} FINAL INSPECTION BY:_______ Date-----------— —:.-.-------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-54 W-1639