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APPLICATION FOR SANITATION� PERMIT i {Complete in Duplicate} _ a. 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. JOB ADDRESS AND OCATION__ - -------------------------------------------------------------------------- -- ------------------ Owner's Name- Address----'- ame_ Address___- ----- ---------- Phone -~ Contractor's Name__________ 4 p ----- - -- ----------------------------- Phone Installation will serve: Residence 'Apartment House Commercial '❑ Trailer Court ❑ Motel ❑ Other ❑ l�- Number of living units:] Number of bedrooms Number of baths[� Lot size____.3* Water Supply: Public systemCmmunity system Private* ❑ ,.. Character of soil to a depth of 3 feet:' Sand ❑ ;-Gravel 0 Sandy Loam L] Clay Loam 0' Clay ❑A*Adobe' Hardpan ❑ \ t TYPE OF INSTALLATION AND SPECIFICATIONS: � :(No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: Distance from nearest well-----!-----------Distance from foundation_____ ____________ Material__~----------.- r -------------------------------- No. of compartments ---- -----Capacity------------------ '-` -I -Liquid depth_'_ 5 ----Size------------- ' ----- -- esspool: Distance from nearest well_________________Distance from foundation--------------------Lining material' ___-__- _.____. ❑ Size: Diameter--------- --- - ------------Depth-------- ------ w _Privy: Distance from nearest well----- Distance from nearest building Distance to nearest lot fine____ 'Seepa e Pit: Distance to nearest wel ____ ce rom fo dafion___la-__.__`Distance to nearest lot ine Number of pits_____/--------__-__" y, Lining Distan Size: Diameter_, 0,/-----Delath Dis osal Field: Distance.frorn..nearest well Linin mDa Stan p - ce from foundation__ --- r--Distance to nearest lot line Number of lines______ 1' Y --: Len th`of each line - �` �_-* Type of filter material ! '_-, g ` "" Width of french----' �----------------------- ------------------ ----- _""--- r '" Yp --'.-DeCth'of filter materi-al____ -0. 1 , Remodeling and/or repairing (describe):__-_- . } .. - -- __ --------- _____ _______ __4_-_________ F f ---------------------------`r+--- nk- ------------ '-_-- r i ffr I hereby certify that I have"'pripared this app'cation and that the work ill be don in accordance with San Joaquin County ordinances, Stat ws, a rul and regu tions f the San Jo uin ocal ealth,Distr' t.' " {Signed} BY:----------- -- O wner an a,,,�� ------(Title)�` (Plot plans, showi size lot, I aon of s stem in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY REVIEWED BY------------4" DATE �+ APPLICATION,ACCEPTED BY________-_________________ ------------ - - - _ ----- DATE__ BUILDING PERMIT ISSUED--------------------- ----------------------------------------------------------- --------- ---------- DATE------------------ -Alterations ------------------ and/or recommendations________________________ " ` - ----------------------------- -------------------------- ---------------------------------------------------- - - -----------------------------------------------------------` - ------------------------------------ - ----------------------------- .l - -- - - -- -- ------------ ------ ----- ------------------------- - ------------- - ----------------------------------------------------------- PERMIT NoiSSUED. ! j ' /-___-_(Date) FINAL INSPECTION BY:_____ Date- ------------- ----------!'�-Z---J-- -�------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street Stockton, California ES-9-21v1 9-54 W-1639