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APPLICATION FOR SANITATION PERMIT Permit No. ------ (Complete in Duplicate) T _ _ 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 twith County Ordinance No. 549. JOB ADDRESS AND LOCA ON.________.-- {' Owner's Name ------------ ---•----- --------------- �u.: ---------------------------- ----------------- - ` Phone' Address---------------------- - -------- ---- .- ---/ M- , ... ti, Contractor's Name____ �_ r w : G { __`------------------------ Phone_.. Installation will serve: Residence ��partment €-louse ❑ Commercial ❑ Trailer Court ❑ Mote! ❑ Other ❑ Number-of living units; /--- umber of bedrooms __ ✓Number of baths ___/_ Lot size _____tc cJ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table If ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay E] Adabe Previous Application Made: Yes No �1" hardpan ❑ ❑ [r•YrNew Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑— TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or`cesspool permitted if public sewer is available within 200 feet.) S zc T Distance from nearesr well-----------------Distance from foundation-------------------- Material--------- ---- No- of compartments--- I ----------------Size------------------- =--•-------Liquid depth------------------- Distance -----CepacitY------------------ Number ----------- - --- � sal I from nearest weir___---___.Distance from foundation___ __._ ___ line /� __-_-Distance to nearest lot __ Number of lines--------� -- ---------Len Length of each line _ _ I7 K g ------� Width of trench.__v !!-------------material- ----------Depth filter material length --------- Seepage Pit: Distance to nearest well___ _ :____._----_-_Distance r r f ation__ Q--___-_--.Distance to nearest lot line_______-. Number of pits----- ------ ----- g materia _--_--- -----.Size: Diameter---�� `` ` Linin mat Depth --------- Cesspool: Distance from nearest well__ _______Di'stance from foundation Lining material----- ------------------- ---------� ��; ❑ Size: Diameter-------------------------- -----------Depth-------------------------- Liquid CapacitY------------------ -------gals. Privy: Distance from nearest well _Distance from Distance building Q � ❑ Distance to nearest lot line - g------- ----- --- ---- --------- --------- Romodefing and/or repairing describe : • -- f ) ------------------------`c � 6' 1 ---- -----------------------•----- ------- --------------------------- I --------------------------------------- _ 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) f DAY&NIGir '_. ----------------------------------------Tite er an ontractor) 1206 mss.Efclssroclo t •-----------•-------r=r ----- :.® 2-701 J (Piot plan, showing size of lit, beation of'sy tefrim in relation to wells, buildings, etc., can{bel pl ed on reverse sde). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------ - f DATE -------------6 REVIEWED BY ------------------------- -------- ---- i ---------------------------------------------------------- BUILDING PERMIT ISSUED---------------------- --- ATE---•-_--_-- -/_I ----------------------------------------------------------- DATE-------- I f Alterations and/or recornmendaf ions: ---------------•------------------ :-------- ---------------------------------------- -----... 1 -------------------------------------------------------------- -------------------------------------- ------------------------------------------------------------------------- ------------•--- ------------- -- -------------- fr ------------- Pr�c �_c _ °1J � �r_cr.�g; h_ ---------------- ---------------- FINAL INSPECTION BY:-------- ----- -------------------------------- C'(_S/S=s - ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street S+ock+on, California 814 North "C" Street Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1-37 F.P.CO.