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Ott ' <br /> APPLICATION FOR SANITATION PERMITYWJL- (e <br /> (Complete in Duplicate) 1�4 <br /> LJ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LO. ATION 1-_ ------------------------ <br /> ------------ <br /> -- <br /> :/-- E - �lf�`' <br /> Owner's Name-------------------- - ---------- Phone------------------------------------ <br /> - --- ------- --------------- <br /> •-• ` <br /> ------ ----------------------------------------- <br /> % <br /> Contractor's Name-•------------ -----------•----------- Phone---------------- ------------ <br /> installation will serve: Residence ffinenf House ❑ Commercial i railer Court ❑ Motel ❑ Other L] } <br /> Number of living units: or of bedrooms 0 Number of baths [—] Lot size------ <br /> ____________________ <br /> Water Supply: Public system Community system ❑ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand p Gravel ❑' Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_________________Distance from foundation_t------------------Material-.-__________________________________________- <br /> �No. of compartments-- - Ca acit -----------------------Size-----------------------------___Li uid de th---------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------_----------------------------- <br /> ❑ DeptSize: Diameter-------------------------------------- <br /> h------------------------------ - - -- ----- <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> El Distance to nearest lot line____ <br /> Seepage Pit: Distance to neares wel - _Distance from foundation_J.-O _.D;stanc�e to nearest lot line__ _' <br /> Number of pits____ _______________Lin in`g,material_!_f+ � ____size: Diameteti�� Depth____---I_Z4______./ <br /> _.DisposalrField: .Distance from..nearest well------------------Distance from foundation--------------------Distance to nearest lot line '`_ ----- <br /> Number <br /> Number of lines-----------------------------------Length of each line---------------------------.__Width of trench__-_________________-_____________ <br /> Type of filter material_________________________Depth of filter material_______________________ <br /> -Remodeling and/or repairing <br /> (descri e) <br /> ----- = �' - <br /> ----------------- - ----- --- -/�� ------------------------- ------ ---- -- ------------ - -------------- • <br /> - �4ti--- --------- <br /> ------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regglations of the San Joaquin Local Health District, r <br /> 4`t r <br /> (Signed) — - ----------------------- _ �1 = (Owner and/or Contractor) <br /> By:---------------_----------------------------- --- ----- (Title) <br /> (Plot plan s,showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> r FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------------------------------------------------- ------ ----------------------------------- DATE----- - <br /> REVIEWEDBY------------------------------- ---------------------------------------------------- DATE------------------------------------ <br /> 'BUILDING <br /> ---v- -------------- ---------BUILDING PERMIT ISSUED-------------------------------------------------------------- --------------------------------------- DATE <br /> -------------------------------- <br /> Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- # <br /> --------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------•-------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------22---------------------------------------------------------------------------- ---------- ---------------------------------------------------------------------------•-----------------•--------------- { <br /> PERMIT No-_c>�_ -- _� ISSUED_-!_/4�4 bS�-__---_--(Date) FINAL INSPECTION BY--------- ------------------------------- t <br /> Date------------------//--r- - =---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 - <br />