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I APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) 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 4 549. JOB ADDRESS AN LOCATION---11,1,;7L --------------D----- ------- ---- ----------------- ---------------------------------------------------------�---`- ---- /� rr 4Owner's Name__ _____ _______ ---_----- ---------------------------------------------------------------------- Phone__ 7 --------e----------------- Address--- _---------------Address--- ------=-- 0---- C Contractor's Name------- ------ =.... `'. r--------------------------------------------- Phone____F-__1f Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other [j r Number of living units:jL Number of bedrooms g Number of baths Lot size______, -----_________ Water Supply: Public system [7f Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe AlHardpan ❑Q 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___-__________________-___-_-______-____-___---_ ❑ 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________________________________________________ VAy ' i / 0` f See Pit: Distance to nearest well____ __________Distance rom f dation___ _---,.____D's nce to nearest lot line_________________ Number of pits_____________________Lining material__ _______Size: Diameter____ -7_---.Depth14- V _ Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line__-______________ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- � Type of filter material-------------------------Depth of filter material-------------- Remodeling and or_relpairing describe ______________4Z________________ __ --------------------------------------------------------•-------------------------------------------------------------- ------ fJ --------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- . 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, an ales and regulations of the San Joaquin Local Health District. IS*Sf ned) _D ' �� `"'' /or Contractor) By:---- ------------------------------------------------------------(Title) �- ---------------------- (Plot plans, showing size of lot, location of system in relafion to wells, buildings, etc., must be filed with this application). f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------- -------------------------------- DATE--------- - --------------------- REVIEWED BY------------------------------------------ ------ DATE------------ BUILDING ----------BUILDING PERMIT ISSUED------------------------------------------------------------------ ------------------------------------ DATE--------- Alterations and/or recommendations--------------------------------------------------- -------------------------------------•----------•--------------------------------•------------------------ + ----------------•-•---------------------------------------------------------------------------•--------------------------------------------•------------------------------------------------------------------------------ ---------------------------------------------------•-------------------------------------- --------------------------------------------------------------•----------------------•----- ------------------•------------ PERMIT No-----t_'.S`; ....... -(Date) FINAL INSPECTION BY-------------- ------------------ ---- Z.- --- Date-------------------------------------- r� 1/ 6 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES—?-2M 9-50 W-1639