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r . t 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 No. 549. JOB ADDRESS AND LOCTION ::----- '�-�' Owner's Name t -------------------------------------------- Phone------------------------------------ Owner's --- ---- ----- -------------------- - - ------------ -----------------------------------------------------------------------=-------- Contractor's Name-.------ ; f F----------- /:� :,----- - ---------- Phone Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size______________________________________________________________ Water Supply: Public system ❑ Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or.cesspool permitted if public s wer is available within 200 feet.) -------- Septic Ta Distance from nearest,well___ Distance fro fo ndati n---f__,Z_____.Materia--------�d�K� _i__________ i2e-- -- _ i. uid de th--------__ , No. of compartments_-__ _____ --t_Capacity___ he_- Z _AX.Aiq p Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- F-1 Size: Diameter--------------------- ----------------Depth---------------------------------------------------- .Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 171 __________________________-___---_ -.❑ Distance to nearest lot line________________________________________________ 'Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------------Distance to nearest lot line----------------- El Number of pits..._------------------Lining material---------------------tiSize: Diameter.........---------------Depth------------------------------- � Disposal a d: Distance from nearest well___ _.Distance from foundation_____ Distance to nearest lot Number of lines_____________ __ ______ -Length of each line_______-- Width of french---------`�� '_-_________. ��---- Type of filter material-------)__- epth of filter material__________ ____ ----- Remodeling and/or repairing [ cribe]:------------------� .____ -t .--------rtl*1------- --------- -------------- "' ---•---------- ----------- `�" .. -----,------------------------------------------------------------------------------------------------ --- -------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 gulations of the San Joaquin Local Health District. (Signed) J --------------------------------------------------------------------------------------------------------(Owner and/or Contractor) BY:----------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- 4 (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). - FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----------- ----------------------------- ---------------------------------------- DATE-------------- --------------- . REVIEWEDBY---------------------------- --- --------------------------------0--------------------------------------------------------- DATE----------- ------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------........ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------ -----------------------------------------------------------------------------------------I--------------------------------------------- PERMIT / d ISSUED----� ------- Date FINAL INSPECTION BY:------ y ----------------------------------------- Date------------------6------1 r ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639