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APPLICATION FOR SANITATION PEROT Permit No. (Complete in Duplicate) Date Issued ......_.._.1...__..... Application is hereby made to the San J aquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance ith County Ordinance No. 54 . SV JOB ADDRESS AND LOCA N- -- --------------- `� --- r �---- ------------- ---_--------------------------------------- Owner s Name--�--••----�---------------•--------------- ------------------------------------- --- ------ ----------------------------- Phone_-------------------------- --- Address--------------------- '� --- Contractor's Name - , � ------ ------- ---------- - ___"-_-__' Z' •-------- Phone .f9._�?i 'v Installation will serve: Resi ence Apartment House ❑ Commercial ❑ Trail r Court ❑ Motel ❑ Other ❑ Number of living units: __/_- Number of bedrooms __., / �r s11_l �^ V_ Number of baths _______. Lot size 7__ U Water Supply: Public system ❑ Community system Private ❑ Depth to ter Tableni �✓ft" '- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe Hardpan Previous Application Made: Yes E] No E] New Construction: Yes El No ElFHA/VA: Yes El No TYPE OF INSTALLATION AND SPECIFICATIONS: ,s<x o septic tank or cesspool permitted if public sewer is available within 200 feet.) Stic T Distance from nearest well-----------------Distance from foundation-------------------_Material_-____-_---___--__.---__-._-__-_-__-_-__-:---_--. No. of compartments---------------------_--Size--------------------------------Liquid_ � depth--------------------------Capacity------------�-f- tr-r� al Fi Id:, Distance from nearest well1.2_ _Distance from foundation___/ ___ -.Distance to nearest lot li er_�._s -------- f Number of lines_______:__f..--_____. ______._-Length of each line__../-�_.__.__-- -__.Width of trench--_�_-`7 ------------------- Type of filter material .-� _..__Depth of filter material-_-__ �[-_-____--Total length------- _s)_�......................... _ S a is Distance to nearest well__!_: 1.___Distanc from foundation____ �_ ___.�Disft nce to nearest lot line----.-1_�... �' � Number of pits.__I..__---__-__-__Lining material_" - z `f.____Depth �----�. -f.... 41- Size: Diameter_.- �z__._ _ 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 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)--------= -- = `"" "_/ -------------------------------------- "gContractor) B --------•------------------------------------------- r`' �, ��4Lgs,-------------- Trtle C: &M—Ci l----------------------------------------- (Plot plan, showing size of lot, location of system relation towetc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---- �, '`` Y------------------------------------------------------------------- DATE-------------- --�- r�� ----------•---------------- REVIEWEDBY------------------------------------------------------------------------------------ ---------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------.............. DATE------------------------------------------------------------- Alterationsand/or recommendations:------------------------------------------------------------------------------------------------------------- -------•--•-------------------------------------- -------------------------------•------------------------------------------------------------------------------------------------•---------------------------------------•--•---•-------•--------••---------------------•---- ----------- -------------------- ----------------------------- ------------------ --------------------------------------------------------------------------------------------------------------------------------------•-- -------------•--------------- ----------•---------------•----------------- --------------------------------------------------------------------------------- ----------------------------------•-----------•--•--------- ------------------------------•---------- ---------------- ------------- -----•-----------------------------------------------------------•-------.---------- -------------------------•------------------------------------- FINAL INSPECTION ------------------------- Date---- ^ ----.r-----•------------------------------------------------ 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 , Revised 1•57 F.P.CO. f