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APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> e�-D �r� S r <br /> JOS ADDRESS AND LOCATION­21-7-JO - ---- . ----- -----=--------------------------------------------------- - - ---- <br /> Owner's Name...... �f� '�------ ------------------------------------------------------------------------------------- Phone---- ------------ <br /> Address--------- ...... <br /> --------Address---------1--r--�--¢------ -------- ----------------- -- - -------- <br /> ----------------------------------------------------------------------------------------------- <br /> Contractor's Name------------W-9-1.7-�------------------------------------------------------------ ------------------------------------------------ Phone------------------------------------ <br /> Installation will serve: Residence g Apartment House ❑ Commercial ❑ Trailer Court ❑ 'Motel ❑ Other ❑ <br /> Number of living units: Q1 Number of bedrooms ® Number of baths [I Lot size--- ___ __s - - ------------------------------ <br /> Water Supply: Public system ❑ Community 'system ❑ Private <br /> s <br /> Character of soil to a depth of 3 feet: Sand E] Gravel El Sandy Loam E] -Clay Loam El Clay ❑ Adobe)( Hardpan ❑ <br /> F <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if Wpublt sewer is available within 200 feet.) <br /> / Mater ��SepticTank: Distance from nearest well___ ____Distance from foundation____.. _ ! -,y'� <br /> • No. of compartments '�� Y Capacity Size �' �[--------Liquid depth - = <br /> Cesspool: Distance from nearest well-----------------Distance from foundation_____________ _____Lining material___________________________-_____. <br /> Size: Diameter---------------------------- ------Depth---------------------- 1 <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____-_--_--_____________________________. <br /> _ Distance to nearest lot line_______________________________________________ <br /> Seepage Pit: Distance to nearest well_____________________Distance from foundation--------------------Distance to nearest lot line____________-____ <br /> Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------Depth---------------------------------- <br /> . ., <br /> Dispos Field'- Distance from nearest well__6�.--_ _.Distance from foundation__ _____Distance to nearest lot <br /> Number of lines________________ ______---------Length of each line__________ �•`_ I .� <br /> �i`�-- --------Width of trench--------�`----'�---------------- ; <br /> Type of filter material___ �__Depth of filter material--------1�a--_____ <br /> Remodeling and/or repairing (describe)-------------------------------------------•------------------------------------------------------------------------------------ ----------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------- <br /> ------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> f I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and' r9 tions of the San Joaquin Local Health District. <br /> (Si ned _ - (Owner and/or Contractor) <br /> g )---- ----- =-=- <br /> � _ <br /> By:-----==----------------------------------------------------------------------------------- -------------------------(Title)---------------------------------------------------------------- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings;'-bfc., must be filed with this application). <br /> FOR DEPARTMENT USE NLY <br /> APPLICATION ACCEPTED BY----------------------------------- DATE------------ p----- 7----------------- <br /> REVIEWED BY-------------------------------- <br />' ------------`---- --- - ------------------------ --------------------------------- DATE----- -------- ----------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------- ---------------------- ------------------------------------ ---- DATE-------------------------------------------------------- <br /> Alterations and/or recommendations:--- -------------•4---------------------------------- ------------------------- <br /> -------- -------- - ------ -- ------------------------------------------------- <br /> ------------- <br /> ----------- ------------------ <br /> ------------------------------------------ --------- <br /> ---------------- ------------------------------------------------------- <br /> -------------------------------� <br /> i <br /> ----------------------------------------------------------------- <br /> ---------------------- --------- ------ -------------------------------------- <br /> -------------------------------------------------- <br /> -----N"" <br /> s f , <br /> k PERMIT No.��___� ------ ISSUED---___-- ----7 ___________(D'ate) FINAL INSPECTION BY:--------:_-`----------------------�" `1"�'-3---.;----------- <br /> Date------------Si j' ^`.-?'�,---- .r ti4. <br /> 'SAN JOAQUIN LOCAL HEALTH DISTRICT n - <br /> 130 South American Street - <br /> R Stockton, California <br /> I <br /> ES-9-2M 9-50 W-1639 <br />