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APPLICATION FOR SANITATION PERMIT 5 (Complete in Duplicate) j 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 Courcy Orciinance No. 544. �// ------------------------------------------- JOB ADDRESS AND LOCATION-- ----�-7 �__�- ---�'�_ --- -- l'�'-r!.��-------------------------------•- - Owners Name---------- ---v------ - --'----------------------------------------- Address ----- - Phone I Address---------------- -- - ------•- ---'-----`�'�------------- --------- ----------------------- - ---------------------------------------------------------------------------------------------------- no ----------------a--------------- p Contractor's Name--------- = - ------- Phone --- ------------------------------------------- +d Installation will serve: Residence ❑ Apartm nt House ❑ Commercial ❑ Trailer Court ❑ Motet ❑ Other ❑ Number of living units: V Number of bedrooms Z2�. Number of baths [Z Lot k size____ � -_--__________________________ Water Supply: Publics stem Community system ❑ Private ❑ �` . 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.) �71 i I 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-------------------------------------- F-1 Size: Diameter--------------------------------------Depth--------------------------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building,_________________________________--_-_- ! I ❑ Distance to nearest lot line_______________________________________________ l Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line__________._-__-I— A ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth----_------------------__ Disposal Field: Distance from nearest well----� ___.Distance from foundation_-_�O_- ---.Distance to nearest lot lines'/___ Number of lines_______________/______--._______Length of each line___________ __ � � ------ �(.Width of trench +�-�-------------------- 1 Type of filter material-_�'� AA� Depth of filter material-_______ ------- Remodeling and/or repairing (describe):------------------ ---•---------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------W- - -7 - -----------------—-----I-------------------------- -----------------------------------------------------------�3-----------------------------------------------------------------------------------------------I---- — ---------------------------------------- -------•- -- ------------------------------ ------------------------------------------------------------------------------------- --------------------------------- 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 regulations of the San Joaquin Local Health District. (Signed) - - -- Qwner-and/or Contractor) ` < ------ BY:----------------------------------- --------------------------------------- ------------------------------------------(Titles (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be fled with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ -- ----------- i6 - --------------------------------- DATE----- .f x REVIEWED BY = � --- DATE ------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------------------------------------- Alterations and/o re ommendatio s: ------------1------------- ---------------------------------------------------------------------- -------------Q-J-- ---------- r. . ---------e)-o------- - --------------------------------------------------------- ----- { --------------•-------------------------------------------------------------------- ----------------- -------------------------------- ----------------------------------------------------------------------- -------- --- - - ------------------------------------------------------------------------------------------------- ----------------------------- --------------------------------------------------------- -------- = -- PERMIT No----- ---------- ISSUED___-_ ._____r' -'__ _______________(Date) FINAL INSPECTION BY:__._______ _________ .__ --L Date---------------------- - - SAN JOAQUIN LOCAL HEALTH DISTRICT 6 130 South American Street Stockton, California `r.y ES-9-2W9-60 4-50 W-1634