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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 LOCATION___!____--------------------�,__-_____�. o , rT---------------------------------------- Owner's Name------------� Phone R I- ------------------------------------------------------------------- Address _11---------�----( _�2or ---------------------------------------------- Contractor's Name---------------- ------------- - -- -- ---- ---------- ------ - ------------------- A- Phone Installation will serve: Residence D4 Apartment House ❑ Commercial E] Mote) ❑ Other ❑ ❑ Trailer Court Number of living unit: [[I Number of bedrooms T Number of baths VJ Lot Water Supply: Public system ❑ Community system ❑ Private Character of soil to a dept0of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX H rdpa z TYPE OF INSTALLATION AND SPECIFICATIONS: . {No septic tank.or cesspool permitted if public sewer is available within 200 feet.}� 04 Septic Tank: Distance from nearest well____,��---_-Distance from foundation______ �•y � - ��1�---- ---.Material.------- No. - -- --- --- ----- - V .. of Comportments_________ -r_____-___Capacity---- _ ---------Size------t } !j �iquid depth__--_*- i Cesspool: Distance from nearest welL________________Distance from foundation--------------------Lining material_______________________________-__ ❑ Size: Diameter--------------------------------------Depth--------------- ---------------- - :Privy: Distance from nearest well_________________________________________b__Distance from nearest building r ❑ Distance to nearest lot line------------------------------------------ ----- + Seepage Pit: Distance to nearest well___________ _____Distance from foundation--------------------Distance to nearest lot line------- Number-6f❑ Number of,pits___#____________ Linin material' ___________ -------Size: Diameter------------------------Depth------------------------ ---- -- .Disposal Disposal Field: Distance from nearest well____SQ__-___Distance from foundation____ _______-Distance to nearest lot line.-_ Number of lines---I--------1_ �� Length of each line_________1�_d_____�____-Width of trench_____,�r -------------------- Type of,filter material_/_f. .___[_ ,Depth of filter material_____- Remodeling and/or' t re airing (describe):------------------ _ --------------••-------------------------------- I --------------- �-------------------------------------------- ----------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------- -------------------------- {--------------�'�"-"`--��» -____ i . ' # _ ______i-4-------------- _____------ __--- _ ----- ___ __ _ __ __ _ ---- ____ _ --- _ _---------- _ _ ------- __ _ -------- ---- ------ _--- I hereby certify that),-ha a prepared this applica+i_ _ on_an_ d__+h_ a+_th_ _e__wor_ _k__br_il_l__6e__d_one_ __in__accor__ dance_ _ __with__S_an___Joaqu_ in__Coun__ty ordinances, tate laws, and rules and- regulations of the San Joaquin Local Health District. (Signed)- - -- .> —--------------------------------------------:-----------------------------------------------(Owner and/or Contractor Br �---------- } _ _ _ -- rte) ------------------------------------------------------------ n _ _ {Piot plas, showing size of Io+, location of system in relation fow ells, buildings, etc., must be tiled with this applica+ion}. FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----------------------------- -- -- ---- DATE-------_-- . I^"1 - V r ----- -- ------- ----- ---------- REVIEWED BY - ' --------- -- --- ------ DATE------ -------------------------- I DING PERMIT ISSUED---------------------------------------- --------------- DATE 4 ---------------------------------------------- Alterations and/or recommendations_____________________________ 7 ------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------•----------- PERMIT No.___�d�_ ISSUED , I _---_-- ___--'-- ---� -�_-_--.(Date} FINAL INSPECTION BY:_____-___�---f/_�- _-- Date -------------------- -- i SAN JOAQUIN LOCAs. HEALTH DISTRICT 130 South American Street . ES-9-2M 9-5o W=1639 Stockton, California