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#;3d r •'' APPLICATION FOR SANITATION PERI BOAT s >: (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. I This application is made in compliance with County Ordinance o.f 549. - JOB ADDRESS AND LOCATION__s"-R-------- a---_-- ------------------------------ ---------------------------------------- Owner's Name_.-F�-------- ---- - - - -- --- ----------------------------- ---------------------------------------- Phone------------------------------------ • S Address ¢ - -------- -----4�-•------------------- --------•----------------------------------------•----------------------------- Contractor's Name---------_--- ------------------------------------------------------------------- A-------------------------------------------------------• Phone------------------------------------ Installation will serve: Residence Vf Apartment House:❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [❑ Number of livingunits: Number of bedrooms Number of baths Lot size____ r � �`d-�---�-1--�--lei-------------------------- Water Supply: Public system ❑ Community system ❑ PrivateX 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.) `l 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 w II------ �---_Distance ori fou dation_______`___-__.Distance to nearest lot line.-h,/-------- °��j Number of pits-------- Lining material__ ___ ,Size: Diameter.___. „�--__.___.Depth___ -_- Disposal Field: Distance from nearest well_-- ---__.Distance from foundation------ to nearest lot line___-! ___ Number of lines-------------�J___��__- ____Length of each line-------w2_Q_-..-________..Width of french---- .0,4 b ----------------- Type of filter material_-X!____ _,/__Depth of filter material___--<1_�� Remodelingand/or repairing (describe)-------------------------------------------------------------------------------------------------------------•----------------------------------•-------- -------------------------------------------------------------------------------•---------------------------------------------------------------------•---------__----------------------------- f ---------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- -----------------------------•--------------------------------------•- --------------------------------------------------------------------------------------------------------------------------------------------------- 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 r fgulati ns of the San Joaquin Local Health District. (Signed) -- ---- -�.... --- �`---`� ""''" --------------------=----------------------------------- {�or Contractor) BY: �.. -------------------------------------------------------{Title) _: '!"Ac_-----__•_---------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must 6e filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------------------------- ------------- DATE--------l�` f REVIEWED BY--------------------------•-------.--------------------------- - DATE-------- � -.-- ---------------- BUILDING PERMIT ISSUED------------------------------------------------------------ DATE Alterations and/or recommendations------------------------------------------------------------------------------------------------------------------ ------------------------ -----------------------------------------------------------•------------------------------------------------------------------------------------------------------------•---------------------------------------------------- -------------- ---•----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- -------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- --------- ----------------------------- PERMIT No._,23 ----------- ISSUED---- ----- --------------------(Date FINAL INSPECTION BY------------_r Date----------------------------- --- - --------------------- ---- ./- 1 ---�-------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California t C� ES--9-2M 9-50 W=1639 �G�