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APPLICATION, FOR SANITATION PERMIT �11 Y 1 r�, (Complete in Duplicate) ^ ! O' 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 County Ordinance No. 549. rS4F4r s • I ?1 - 2,�or�3 JOB ADDRESS AND LOC ION _ _--------------------- _- Owner's Name-------2/_� -- --------------------- ,--------------------------------------------------- Phone------------------------------------ Address------------------ ©� Contractor's Name---------------------- ------- -- ------------------------------------------------------------------------------------------------- Phone---------------------------------- Installation will serve: Residence Ap ment House ❑ Commercial ❑ Trailer Court ❑ Motel 0 Other ❑ Number of living units: V Number of bedroom^ mber of baths [ / Lot size---------- _-_�__ - ----------- Water Supply: Public system El Community system rte ❑ {ten Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ , b TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep is Tank: Distance from nearest well--- __Distance from foundation-_.._- -- .Mater'al.___---- a No. of compartments- ----------- ------------Capacity.---� .- ---Size- -_ -- _--Liquid depth-----___----------- CesspoIIIol: Cesspool: Distance from nearest well______________-_Distance from foundation--------------------Lining material------------------------------------- ElSize: Diameter--------------------------------------Depth---------------------------------------------------- Privy: Distance from nearest well----------------------------------------------__Distance from nearest building------__----------_------____------__--� ❑ Distance to nearest lot line------------------------------------------------ Seepage Pit: Distance to nearest well---- ----------------Distance from foundation--------------------Distance to nearest loft fine--__----__------_ ❑ Number of pits----------------------Lining material-----------------------Size: Diamet�----------------------Depth------------------- ---- ---- Disp sal Field: Distance from.-near well---�ri3O___Distance from foundation-----/,,�_--._ Distance to nearest lot line_; Number of lines----- -__ _._ en th of each line, �' _ tr ------ � � _ /� g �'----- = �/✓idth of trench----___-- - Type of filter material___r5� KDepth of filter material------- Remodeling and/or repairing (describe):-------------------- u ---- ------ , ------------- -------------------- . -----. -- ----------- - �-------'= ------- - -------------------------------------------------------- ------------------------------------------------------------- ------------------------ -- --- -='-°------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-- a ------- --- ----- -•------------------------------------------------------(Owner and/or Contractor)- By:---------------------•----------------------------------------- --------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be flied with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------------------------------- ------------------ DATE-------------------------------------- REVIEWEDBY---------------------------------------------------------------- -------- -- - - ------------------ DATE---- ------ BUILDING PERMIT ISSUED ----------------- DATE----- j' --�;--- Alterations and/or recommendations: -- ------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------I----------0------------------------------ - - ----------- -------- • ------------------------------------- ' ---- ------------ ---------------- _ ----------------------•----------------------------------- ---------------- PERMIT No------------------------- ISSUED------------------------------------------(Date) FINAL INSPECTION BY:--------�43- - ------------------------------------------ Date---------- f SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California E5-9-2M 9-50 W-1639 J