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APPLICATION FOR SANITATION PERMIT i (Complete in Duplicate) f` 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 CATION____,!-__zqf---� SQ-_,_ - ------ -- 41 � -- --- Owner's Name ---�---- � Phone ------ Address � ------- ------------------------------------------------------------------------------------------------------------------------ Y 4 . p 1�j --- Contractor's Name�- --- Phone g��'f �e_ ! b Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court [❑ Motel p Other ❑ Number of living units: t] Number of bedrooms j7-,N _ umber of baths Wr Lot size_-- '�---Q ----------------- Water Supply: Public system 9 Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- —AA - Cj No. of compartments------------------ -------Capacity-----------------------Size--------------------------------Liquid depth-------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__________-_________________________. ❑ Size: Diameter------------------------------- ------Dept h---------------------------------------------------- .'Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- Distance _____-____-__-_- _----- _----_-_-_____Distance to nearest lot line_______________________________________________ "Distance i Seepage Pit: Distance to nearest well---�--�--_—___Distanceir1.A?A4-&ze: m f ndation______XAp____.Distan veto nearest lot line----./-T-- Number ine____ _______r Number of pits______Z____________Lining material_S--- � Diameter------,�-_______...Depth ------ is osal Distance from nearest well..................Distance from foundation--------------------Distance to nearest lo ------- Number -__-.Number of lines-----------------------------------Length of each line------------------------------Width of french-------------------------------- Type of filter material-------------------------Depth of filter material___-____________-______ Remodelingand/or repairing (describe)--------------------------------------------------------------------------------------------------------------------------------•----------------.-.- -------------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- 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. It (Signed)-------- " f ".�C ----------------------------------------------------------- --, /or Con+ractor) By:----- ."`-----'"� ------------------ ----------------------- (Plot plans, showing sae of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------------- - DATE---------------- ----_ i REVIEWED BY--------------------------------------------------------- ------------------------------------------------ DATE-------------- ------------------------------ BUILDING PERMIT ISSUED------------------------------------ ------------------------------------------------ DATE-------------------------- - - Alterations and/or recommendations:--------------------------------------------------------------------------------------------I---------------•-------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------- ----------------------------------------------------------------- --- - -------------------•----------------------------------------------------A -- ---------------------------- f PERMIT No.-?- --------- ISSUED-------- ----�� -- ---------(Date) FINAL INSPECTION BY---------------- -- --_------------------____-- Date------------------------------- l--------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street Stockton, California ES-9-2M 9-50 W-1639