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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ------ 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 Ordin ce No. 5v. JOB ADDRESS AND LO TION- Owner's Name----------- ----)& ------------------------------ ---------------------------- Address------ - ------- ------ - �L- - - Phone------------------------------------ - -- --- - -- ---------- Confractor's Name---- ----• C -----------:.,� - ------- ---------------------- - - - -------- -- - ---- ----------- - ------- ol, -------------------❑-------------------------------------------- Phone -`Aparfmenf House D Commercial El Trailer Court E] Motel El Other Ej Installation will serve: Residence 2? Z Number of living units: ---/ Numbe�';f bedro-orns-j-- Number of baths I--- Lot size -----s;�T-' Wafer Supply: Public system g?,,�C-o mmunity system E] Private ] XX17-6--------------------------- _-] 'Depth to Wafer Table 3�. Character of soil to a depth of 3 feet: Sand' El' Gravel F] Sandy Loam E] Clay Loam Ej Clay 0 Adobe 91--<ardpan 0 Previous Application Made: Yes [-] No UKNew'Consfrucfion. Yes El No 2-�IPHA/V& Yes El No D TYPEOFINSTALLATION AND.SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) n1c: Distance from nearest well__--________-___Distance from foundation--------------------Material No. of compartments--------------- Size------------------------------- Liquid depth--,------------ --------Capacity_______________________ -kr �Wstarice from f6unclafio;n-�-- Disposal d: Distance from nearest well-/ A-� !i-Disfaince to nearest lot line_____A Number of lines Length of each line Type of filter m ----- --- --------------Width of trench----- -7 ateri'l- --�D4, -----Depfh of filter material___`_ ...........Total length--------- ------------------- I f ndafl,n'---.,:? -- -------------------- Seepaq Distance to nearest weI12� I ........Distance to nearest lot 6e- Number of pits------/------------Liningisfaa I malerin Cesspool: Distance from nearesf-well-----------------Distancefoundation--------------------Lining --.S;ze: Diarriefer-,33----------Depth-6; --------------------- S�ze: Diameter from foundafion--------------------Lining material------------------------------❑ ------ - ----------Depth------------------ ----------------------------------Z----------------Uquid Capacity ----------------------------gals. Privy, Distance from nearest well ❑ Disfance to nearest lot line-------------------------------------------------Disfan-ce from nearest building------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ Remodeling and/ repair-ng n pg ai i (d k1-4 .� escri --------------- ------------- - ------------ ---------------- ------------ --------------------------- ------------ ------------ --- ----- -------------- --------------------e------------ -----------------------I-------------------------------------------- ---------------------------------- ---------- ---------------•-------------------- -------------------- -------------- -- !�t- --------------------------------------------I------------I-----------------------------;------------------------------------------------------------------------------------ I hereby cer at I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, SfoeflaW4, and rules and re olations of the San Joaquin Local Health Disfricf. (Signed)-•------- --•7- &ttiL ----------- --------------------------- ------- - -- ---- caner and/or Contractor) -------------m-----(Title)-- ----------- (Plot plan, showing size of lot, location of system in relaf ion to we buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY________________- -- ---- ----------------------- REVIEWED BY ---------------- DATE----------- REVIEWED ----- --- . . --- --------------------------------- DATE ------- ----- ..... BUILDING PERMIT ISSUED --------------------------- -------------------------------------- DATE Alterations and/or recommendations:__._____._.__.___ - -------------- ---------4--�---------------------------------------------------------------------------------------------------------------- ----------------------------------------*-------------- ------- -----ovt-------------------------------------------------------7---------------------------*----------------------------------------- --------------------- ---- ------------------- ----------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------ ------------- --------------------------------------------------------------------------------- -------------------------------------------------------------- ------------------- ------- ----------------------------------------------- FINAL INSPECTION BY - --------------------------- Date------------- 7 - -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 Wait Oak Street 132 Sycamore Street "C" Street S+ock+on, Califo 914 North.rnia L*di, California Manteca, California Tracy, California ES-9-2M Revised 1-57 F.P.CO.