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{ APPLICATION FOR SANITATION PERMIT Permit No. 57. ` (Complete in Duplicate) Date Issued __, : / ` --r 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 Vunty Ordinance No. 549,�r�� r �� , r JOB ADDRESS AND LOCATION... a' __- .---—- _ c J t -------------------------------- 'So -� (�t^c _�c---- 'S� L � _ n Phone---------------------------`-�-'--'-- - . ______- --—,____ ___________________Owners Name----------- - _- Address----------------------------------- -------------------------------------------- -------- ' -t--t---�-------l------------------•--...------------ 4-� CO --- Phone----Y` ----- Contractor's Name-------------------------------------------- ------ -------- - -- - -------------------------------- - Installation will serve: Residence Apartment House ❑ Commercial El Trailer Court ❑ Motel ❑ Other E] Number of living units: _'�'_._- Number of bedrooms _= __. Number of baths / Lot size -_____-..-� --f --1 -'� ------___.__._ i + i Water Supply: Public system ❑ Community system P( Private ❑ Depth to Wafter Table _.:_____ ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes,' No ❑ New Construction: Yes;, No ❑ 4 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) • - ` �G, �� ,., �Aj No.-of compartments ) Size__ - Liquid depth`- --- CapachY----------------`------ Disposal Field: Distance from nearest well....)'-�-.Distance from foundation-----/�--------Distance to nearest.lot line ________ �' Width of trench.----------�------y It--------•-- Number of lines__--____'_.__`}_--____ __ ._Length of each line- ______-___.--,---_._ Type of filter material_"-----Depth of filter material--------i_�--._____Total length________________��:--.�----------- r 1 Z Seepage Pit: l Distance to nearest well------ ' --'_____________Distance from foundation_______.-______.___.Distance to nearest lot line----------------- Number of pits-----------------------Lining material-----------------------Size: Diameter-_.! `--Depth---- - -----_--------------- Cesspool: Distance from nearest well----------------- from foundation-----._..-----------Lining material------------------------------------- ❑ Y Size: Diameter-----------=------------------------Depth------------------------------------- = Liquid Capacity gals. Privy: Distance from nearest well--------------------------------------- ---------Distance from nearest building----_------------------------------------- ❑ Distance to nearest lot line----------------------------- ------------------------------ --------------- t Remodeling and/or repairing (describe)=-- ------------- ---------- ------------•-•---------------•-------•---------;--------------------------------._... -- - ---- -- = ------ -------------------------------------------------------------------------------------------------------------------------------------------------- ! hereby cer y that I have prepared fhi application and that the work will be done in accordance with San Joaquin County i ordinances, St a aws, a rules and regula i ns of the S Joaquin Local Health District. ' ------------- -_-------- wner and/or Contractor) (Signed)-- {O By:---•--------------------------- - -- '---- --- -------------------- (Title) - -- - --- --------------------------------- - i (Plot plan, showing size of lot, location system in relation to wells, buildings, ;+c., can be placed on reverse side). FOR DEPARTMENT USE ONLY s APPLICATION ACCEPTED BY----------------------- f DATE t�I f REVIEWED BY------------------------------- -- DATE J BUILDINGPERMIT ISSUED---------------------------- -------- DATE-------------- ----------------------------------------------- Alterations ----------------------Alterations and/or recommendations------------------------- ---- ---------------------------------------------._....-------------------------------------- - - - ---------------------------------- r t ----- ---- -----------•---------------------------------------------•---------------------------•-------------- ------------------------------------------------ ------------------------- ------ ---------------------------•------------------------------ ----------- ------------------------------------------------------- ----------------------------------- ---------- ----------- ---- � � e/ ------------------ --�`�-- -••------------ ------- FINAL INSPECTION BY------------------------------------------------- Date------ i. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sir"+ ft Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100