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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) is hereb made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Application y This application is made in compliance with County Ordinance No. 5 -v �----- --- --- ------ ----- --------- Phone-S JOB ADDRESS AND L TION __SSG -- -------------------- . __.. ,p� , Owner's Name -- !� lY-- ----------------------- - -- -------- Address___.______._ - ----- ,�f � �h_!_�$--- Phone--- ------ -- -- 14 Contractor's Name----------------------------------------------- Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ installation will serve: Residence Apartment House ❑ 'f ----------- Number of living units: Number of bedrooms Z Number of`baths LA Lot size------- Water Supply: Public system� Community system ❑ Private ❑ Adobe Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available wi+hin on- feet-- Material_________________________ ------------------------------------------------ ' Septic Tank:. Distance from nearest well_________________Distance from foundation Liquid depth-------------------------- No.No. of compartments--------------------------Capacity_--------------------- Distante from nearest we44_______ Distance'from foundation--------------------Lining materia---------------------- Cesspool: - ❑ Size: Diameter----------------------- -------------Defth--------------------------------------------------- F1 ----- ------ ------------ --- -_--- -"___--_-"---'��--__-"Distance from nearest building------------------- - --------------------- FPrivy: s Distance from nearest well_______________ ❑ � Distance to nearest lot line--------- -----------==-=--- ----- --- ------- Seepage Pit: Distance to nearest well____________________mD{etaai e from foundation Diameter Distance tonearestlot line.------- - ❑ Number of pits----------------------Li s Disposal Field: Distance from nearest wel4/W-49.---Distance from foundation_ir _________--Distance of frto ench tline-- I -' -----_--- --Length of each line___��------------iT--- Number of lines--_L-l�- ---- -- ------ g Type of filter material !--f�'�`k-Depth of filter material_-__/�- -------- Remodeling and/or repairing describe): -___ - -� ,,. � � A � �Rf -------------------------------------------------------------------------------------- - ------------------------------------ -------------------------------- ----------------------------------------------- --------------=-done in accordance ce with San Joaquin Coun ty I hereby certify that I have prepared this application and that the work will be ordinances, 5ta{e and r s and r u ati ns of the San Joaquin Local Health District. -/ (Orer and/ Contra tor) i (Signed)---- /� - ------------ ---------4 �------ -----(Title)-------- r ------ -- -- By:------------------------ --- -- [Plot plans, showing size o lot, location of system in rela+ion to IIs, buildings, etc., must be fled i{h #his application). FOR DEPARTMENT USE ONLY DATE----- -----/�r -�� --------- APPLICATION ACCEPTED BY____________ ___ _____ -- -" ------------------------------------------------- - DATE ---------------------- --------------------- -'---------- REVIEWED BY----------------------- ------ ----------------- DATE-------------- -------- _< - ----------------------------- BUILDIN'G PERMIT ISSUED---------------------------------------------------- - ------------------------------ - .----------------------- ----------------------------------------- Alterations and/or recommenda+ions:___________---------------- --------------- ------------------------------------------------------- _ --------------------- ---------------------------------- _ ____ ___________ PERM IT No. ISSUED /----------(Date) FINAL INSPECTION BY--------- -------- ------- � � � -- --- Date---------------------------- ---- ------ ---- 4 t � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9.50 W-1639