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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 /> , D.c. ✓F <br /> .[OB ADDRESS AND LOCATION---- S //------------------- -- --------------------------------------------------------------------------- ------------------ ------------------------ <br /> ' __ -------Owner s Name------------------------------------- J"V-� <br /> ------ Phone------------------------------------ <br /> /o 'r /Vv A-.,e /F - <br /> Address----------------------------------- --------------------- - ---- -------------------------------------------------------- <br /> Contractor's <br /> Name------------------------------ ----------•------------------- - ------------------------------------------ Phone---------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ ,Motel ElOther ❑ <br /> Number of living units: 0 Number of bedrooms a— Number of baths U� Lot size_________!____ '�-----• <br /> Water Supply: Public system ❑ Community system ❑ Private <br /> Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam E] Clay Loam El Clay E:1Adobe Hardpan ❑ <br /> t <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ILA <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic ank: Distance from nearest well____�bf istance from found'tion-----1,p---------Material_`_ ``J �t <br /> ------ <br /> No. of compartments-------- ^----.-____--Capacity_ :XSize__.._--•---•-------•------------Liquid depth-------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------------- _________. <br /> ❑ Size: Diameter--------------------------------------Depth--------------------------------------------------- • <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> El <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-----_---------------.Dept h--------------------------t----- <br /> Dispos Field: Distance from nearest well__-a-Distance from foundation----�n_-______Distance to nearest lot line_ r___..___ • <br /> Number of lines_______;_.y _-___ -Length of each line________�y _u--____Width of trench____:_�__,/__ ____________ <br /> ` 7"` <br /> Type of filter material____ __f'Depth of filter material______4e_________ <br /> Remodeling and/or repairing (describe):------------------------------------ <br /> 1 ----------------------------------------------------------------------•------------------------------------------- <br /> ---------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)________ _ (Owner and/or Contractor) <br /> ------ -----------------------------------------{Tit{e) <br /> (Plot plans, showing size of lot, location system in rela+ion o wells, buildings, etc., mus+ be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ �--------- _ DATE >� -- --qtr/------------------- <br /> REVIEWEDBY---------------------------------------------------------- ------ DATE- <br /> BUILDING <br /> - <br /> BUILDINGPERMIT ISSUED------------------------ ----------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations:-------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --•------------------------------------------------------------------------- -----------------------------------------------------•--------------------- <br /> ---------------------•------------------------------------------------------------•----------------------------------------------•---------------------- <br /> -----------•-----------------•------------------•--------------------------------------------------------------------------------------------------- <br /> - - <br /> ----------------------- <br /> - -------------------------------------------- ------------------- - <br /> •-----------------••---------------------------------------4, l 1 1 J <br /> ISSUED - /I/--5:7/------------- DateFINAL INSPECTION BY:----------W Y----1-------- ------------------------- <br /> PERMIT Nol�___.� --- ( l <br /> Date_ vi --------------•----------- <br /> ------------------------- ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />