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APPLICATION FOR SANITATION PERMIT Permit No, 1��?._.. .__>_ (Complete in Duplicate) Date issued Application is hereby made to the San Joaquin cal Health District for a permit to construct and install the work herein described. This application is made in compliance w' h Co y Ordinance N . 549. JOB ADDRESS AND LOCATIONt✓ -- ---------` /: - ----- - "' � �'+�= �j _ ,/ �"'' Owner's Name �---------- ---�/� s'+��-fir 'd:'I� .1 ----� Phone ----- Address ern. er 'e4 ------------------ ----------------------------•------------•--- Contractor's Name---------------------------------------------------- ------------•-------------------------------- Phone---... ---- Qs Installation will serve: Residence 16 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ _j Number of livingunits: ___1__'___Number of bedrooms _ fo_. Number of baths A-. Lot size ---!___-�i-_��r______________________________ Water Supply: Public system ❑ Community system ❑ Private i Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay a Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) is Tan Distance from nearest well-----------------Distance from foundation--------------------Material---------------------- ------------------------------- No. _____.________ ._--._-_______________-.--___No. of compartments--------------------------Size---•--------•------------------Liquid depth--------------------------Capacity----------------c ` Disposal Field: Distance from nearest well/19� .._Distance from foundation_A r.___._.Distance to nearest lot line%__f Number of lines....... ......... n Length of each line____/=__0-------------Width material----- material---- length_____6-9_ ------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- F-1 Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth---.-----.-_--__--____-------___- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------.______. Size: ,Diameter--------------------------------------Depth----------------------------- Liquid Capacity_ ---.gals. Privy: Distance from nearest well---_---------------------------------------------Distance from nearest building__---_______-____-____-__--_-__-_-.-___._. ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------_-------•---------------- Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------•-----------•---•------------- --------------------------------------------------------------------------------------------------------------------------------- •--------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinan , a e and rules I tions of the San Joaquin Local Health District. . .--- ---- . r - Contractor (Signed)... - _ By:------------------------------------------------------------- ----- ~== lTitlel ��on �`------------- n (Plot plan, showing size of lot, location of sy tem in elation to wells, buJ'dings, eta., can be rse side). " OR DEPARTMENT USE ONLY APPLICATION ACCEPTED B V DATE ------------------------------------------------ REVIEWEDBY ------------ --------------------------------------------------------------------------------- DATE BUILDINGPERMIT ISSUED---_--------------------------------------------------------- ------ DATE------ ------------------------------------------------------ Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------------------------------------------ _------------- ---------------------------------------------------------•--------------....------------- ----------------- ---------------•••-------•-------------•------------•--------------------•-----------------'-----------------•-- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------•--- --------------------------------------------------- ------------------------------------------------------------------------------------ ------------------------------------------------------------ -------------------------- FINAL INSPECTION BY---------------- Date.:--------------------- -----------------------------_---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100