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APPLICATION FOR SANITATION PERMIT Permit No. .z _s2__(1._ _ (Complete in Duplicate) y Date Issued . U V �'j• . Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 10 This-application is made in compliance with County Ordinance No. 549. 57 JOB ADDRESS ANQ CATION -------- ---- --&---------E-----------!�Z'rxE-o __7 --------------------------- 14 1 ---------------------- ----------------- Phone---',/=_�r .-'-_�__._-- Owner's Name---------- - -- -- 1 - Address------------------------------ - ---�� ,e► p�+ Contractor's Name : + ` PJ. f r Phone �� d LP0- ------ installation will serve: Residents Apartment House ❑ Commercial E] Trailer Court E] Motel E] /Other E] Number of living units:___ Number of bedrooms .1--:Number of baths �Lof size __ -__-__J__ 1C- --f----------------- Water Supply: Public system Community system fl Private ❑ Depth to Water Table*10 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 5d Hardpan ❑ Previous Application Made: Yes ❑ No %,, New Construction: Yes ❑ No TYPE OF INSTALLATION: AND SPECIFICATIONS: (No septic fank or cesspool permitted if public sewer is available within 200 feet.) is T nk: Distance from nearest well_________________Distance from foundation------------- Material------------------------------------------------- l No/'of compartments--------------------------Size--------•--------------•--------Liquid depth Capacity i sal Field: Distance from nearest well----------------- from foundation--------------------Distance to nearest,lot line----------------- Number of lines-----------------------------------Length of each line------------------------------Width of french---------_---.--------------------- " Type of filter material-------------------------Depth of filter material---------- length-------------------------------.._________ i Seepage Pit: Distance to nearest well-WO-Ne----Distance fromundation./,0____.-____.D'sfanc to nearest lot line-. Number of pits.�hGP-___-____Lining material__ -_Size: Diameter___ �i---------.Depth.__-+ ____---------------- Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material----------------------.___________--. ❑ Size: Diameter----•---------------------------------Depth----------------------------------------- ------Liquid Capacity----------------------------gals. i Privy: Distance from nearest well----------------------------------.---------------Distance from nearest building_____-_-____----______________-________- ------------- ❑ Distance to nearest lot line-----------------------------------------------•----------------••----------------------•-------------------------------------- Remodelin and/or repairing describe -----------------------•------------•-•-• . &- 1161 I hereby certify that I have prep this application and fhaf the work will be done in accordance with San Joaquin County P ordinances, Stat laws, an rules an r ulations of the San Jo.. urn Local Health district. (Signed) ' Owner an or Contractor -------- ---- ---�=/ By:-------------- --- - ----------- - --e+�o --- ------: - -------------------(Title)-------- -- - --- -------------.----- (Plot plan, showing size of lot, location of system in relatills, buildings, etc., can be place on reveirse side]. F FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- ------ ------- DATE / �� - Z. , REVIEWEDBY-------------------------------------------- - ------------ ---- - ---- ---------- DATE BUILDINGPERMIT ISSUED-------------------------------------------------------------------------- ------------------------- DATE.------------------------------------------------------------- Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------ -------------------------------------------------- -------------------------------------------- -------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ ------------------------- -------------------------------------------------------------------- -------------------------------------- -------------=------------------------------------------------------------------------------------------------ --------------------------------------------------------- ----------------------------------------------------- ----------------------------------- ------------------------------------------------------------------ FINAL INSPECTION BY:--------- -------------- Date---- -- - -- --------------- ------------------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Mantecar California Tracy, California t ES--9-2M 8-51 Revised W-2100