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4 APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Applic tion 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 -LOCA--T- N------------S- ----.--. - --- r — -- ' --- ----��-�-- - ':. Owner's Name 111- ----------------------------------------------------------------- ----- Phone_Address__.--- e" --- ontractar's Name-------- ---------------------------------------- ----------------------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑/Motel ❑ Other ❑ Number of living units-jp Number of bedrooms 3 Number of baths of sizeP- — Water Supply: Public system ❑ Community.system ❑ Private [ate Character.of soil to a depth of 3 feet:- Sand ❑ Gravel ❑ Sand Loam Clay Loam Clay 1 Y ❑ Y ❑ y ❑ Adobe Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 �a Septic T�nk;"'� Distance from nearest well_J -------Di-stance_ from foundation_d_E3________--Material __ t � . ___-- "' , No.,of compartments-___--___' �__--_---Capacity-'k-4-_d Size___ Liquid depth--- Cesspool: Distance from nearest well �_`_--- _ _Distance from ` ---.-. fou d__-- Lining material--- �r .�_ Size: Diameter-----.`-r-------------------------Depth----.'0 --- ; Ff Privy: Distance from nearest well------------- I---------'---------------------------Distance from nearest building ❑ Distance to nearest lot line__________________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation___________________ .Distance to nearest lot line_________________ Number of Pits---------------------Lining:material-----------------------Size:Diameter------•----------------.Depth-------------------------------- Disposal Field: Distance from nearest well j'D__------Distance from foundat-on__l J_��_ JJ ____-Distance to nearest lot fine__--_____-- Number of lines______ ______________ Length of each line__s� ______ -t#_----_-Width of trench___ Type of.flter_materiala�Li�,�_-_-------Depth of filter material___-J�_____________ LRemo�ddeliandl/or repairing (des ' 'e} ______ _- ------------------- ---------- ------------------------ - 1 ------------- ------ - - - -- ---------------- -------------------------- ------------------------------- - ------ --- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinancesState laws, and rules and regulations of the San Joaquin Local Health District. (Signed)11 ----�-------------------------------------------------------------- ( (Owner and/or Contractor) BY:------- ---------------------------- ------ --------------- Title -------------- -- ------ ----------------- {Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY________ _�_ DATE ------------------ ----------------- REVIEWED BY ,• ----------------------------------------- DATE_ - _ BUILDING PERMIT ISSUED-,_ _ ------- - -------- -------------------------------------------------------------- DATEAlterations and/or recommendations: _ ------•------- a - s "- =____________, __ -----•-------- ---------------•-------------- - ------ 14 3 --------- -----:------------------------------ • _ _ -----------------------------------------------------------------------—-------------------------------------- ---i/ — -------------------- ------------------------------------ ---------------------------------- -s-- ------ PERMIT No. -a'i„ ` !�- _____ ISSUb�d _-,�.,� (Date) FINAL INSPECTION --- ------------------- ------------ Date.---, SAN JOA UIN LOCAL HEALTH DISTRICT Q 7 130 South American Street .• f == ES-9-2M-9-50 W-1639 Stockton, California x +'