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APPLICATION FOR SANITATION PERMIT 4:7 (Complete in Duplicate) Application is hereby made to the Sari Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compkance'..with County Ordinance No. 549. ode [I JOB ADDRESS AND LOC TION------` 7 ---�----- - - = - - --------------------------------------------------- �.p Phone------------------------------------ 1 Owner's Name------------------- -.1--- ------ a. Address---------------------------- Contractor's Name.-------- - Phone----------------------------------- Installation will serve: Residence WApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: umber of bedrooms Number of baths [ ] Lot size-------------I_.___ _ _ �_____--____---------------- 1 Water Supply: Public system Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam El Clay Loam ElClay E] Adobelardpan ❑ TYPE OF INSTALLATION AND.SPECIFICATIONS: `f (No septic rank or cesspool permitted if public sewer is available within 200 feet.) U� Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material_--______----_______________-__-_______________- ❑ No. of compartments---------------- --:-Capacity ------Size_-----------------------------Liquid depth-------------------------- Cesspool: Distance from nearest well-------------------Distance from foundation--------------------Lining material_________.------.------------------ . ❑ Size: 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 lot line----------------- ❑ Number of pits--------------- _L'ining .material-----------------------Size: Dia#nee� Depth _- c � �__pi os Field: Distance from nearest w II___�"'"-"___Distance from foundation. ___:(j -,'-�-Dis#ante to nearesf lot lirie_I____!d___- -��"�--'Num-ber-of lines,_____ Length of each line------- __ - Width of trench----------- ------------------- _ - X-4---- Type Type of filter material____�_i_T--RDALDepth of filter material_________l ___.---_ r Remodeli g a /or repairing (desc be): Wf��.�Ifk --- ---- — --------- --------� l\r(({ �p yI(/j/�� ___________S___ _ _ __ _�h _ __ __._ ------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------- ---------------------- 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 rules and regulations of the San Joaquin Local Health District. 4 ----------------------------------------Owner and/or Contractor (Signed)----------- a�/ / hBY: P�------------------------------------------- -------------------------------------------- (Ti+le) (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). I F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------'---- -- - -------------------------------------------------------------- DATE REVIEWED BY--------------:----------------- ---- ---------------- -------------------------------- DATE---------- - -------------- --------- ----------------- - -------------------------- - - BUILDINGPERMIT ISSUED--------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:_-- - ---------------- ------- ---- / - ---- ----- ____________ `°� .�-_---------- rS; -------(Date) FINAL INSPECTION BY:- �•- PERMITNo---- -------------- - ISSUED-------- ---------------- --- ------ --- ------------- ------------ Date----- ----s3------------------ ------ l SAN JOAQUIN LOCAL HEALTH DISTRICT r 130 South American Street Stockton, California ES-9-2M 9-50 W-1639-