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APPLICATION FOR SANITATION PERMIT Permit No, (Complete in Duplicate) Date Issued ___. SS�-- 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.Ordinance No. 549. [ ' --- JOB ADDRESS AND 'LOCATION - �_� ia/pne_ Name_ ----- ------------ -- - -- ------ Owner s T �- - Y `- _-_ ___ _______________ ------- ---------------------------- Address------------- V -_..------- -_� �-- - � - Phone.--- -----•------- Contractor's Name---------------- ;i Installation will serve: Residence Apartment House ❑1,.Commerc'sal ❑ Trailer- Court ❑ •Motel ❑ Other ❑ ' Number of baths _-j.`__ Lot size __-4:9e-------k----A41r `------- Number of living units: "_�-.-- Number of bedroom's _ Water Supply: Public'system Commursity..system ❑• Private ❑ Depth to Wafer Table':-f4[lft .I # et: Sand Gravel �] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe JK+Hardpan ❑ Character of soil to a depth of 3 feet: r ❑ A Previous Application Made: Yes El No New Construction:, Yes E] No FHA/VA: Yes ❑ No E OF INSTALLATION AND SPECIFICATIONS: TYPE (No septic tank or'cesspool permitted.if public sewer is available within 200 feet.) ept' A: Distance from-nearest well------ _________Distance from foundation------------------ _____ _-------------- No..of compartments---------- - -------------------- Liquid depth * - = _ Capacity------- • well -D stance '� from foundation--------�_-----------Distance to nearest lot line_______._____._. F isp at i Id: Distance fcom'neares# e Number of lines-----=-------- --------------------Length of'each line Width of trench. \ CC(iii11i�" Type of filter material------------- -,'-------Depth offilter material-------=--------------Total length--------------------------------------------- '�- - ^` �'"'—" N; Dista cn e rom'found'afion=__.0 _.___.Distan 'to nearest lot line-��----- Seepage Pit: bistance to nearest well__-_ -�-- ,3-,}i- --------.Depth---- - Number of pits_-..___/____.__:_--Lining material-____ ° �-.- Size: Diameter__._,3.,? j sp ' Distance from.nearest well------------ Distance from-fouhclation-_______-__ -____.Lining material_____________________________________. Cesspool: _Li Liquid Capacity-----------------------------gall. ❑ Size: Diameter---_-=-----'---------- ------ ------Depth_ = 9. p Y .. r 3 =-----_-Distance from nearest-building------------^-------=------=----• i Privy: „� .. . Distance from nearest well_ -- - —^ J--------- ❑ - �..,,_-4-Distance to nearest lot line--r-------!t".n------------ ------------------ -------------- ---------------------------------------------------- -- -------•------------------- --- Remodeiing and/or 'repairing (describe):__ ---. �__ ----------- --- ----------------------------- - ` : Xa, % f ' ��'��_..----- ------------------------------------ ----------------------•-------------------------•-------------------------- be done in accordance with San Joaquin , t __ I hereby certify tha+ I have prepared this application and;that the work will County ordinances, State i and rules an regulations-of the San Joaquin Local Health District. [Signed) :,. ------- / ,L1S - - C✓ Owner and/or'Contractor) / �, ©, 14 4.1 - e)------. ----------------- --------- By:--------- -... =•---------•------- -- - ,(Titl1 ; (Plot plan, showing size of lot, location`of system in relation to'wells;'buil etc., can be placed on reverse side): 1 FOR DEPARTMENT USE ONLY " ' 1 = DATE-------- r c7 APPLICATION ACCEPTED BY---------------------- ------------------ G� REVIEWED BY - �.. . ---:__. _ ___ -- -° DATE-------- - -- r:--- -------- _ -------- PATE-------=---------------------=-- ----•----------------- -- BUILDING PERMIT ISSUED---------------------------- ----- Alte tions anA/or recommendations- -- - - " l - - ----- - - - _ ------------ ------ ----- ------- ----------- ----------------------------------------------- ---------- ---------------; --------------- --- FINAL INSPECTION BY::-%�. - -= - -- - ---'-=---- ------------- Date--- `r, SAN JOAQUIN LOCAL HEALTH DISTRICT ' 130 South American Streef 300 West Oak Street 132 Sycamore Street 814 North "C" Street 5}oekfan, California Lodi, California Manteca, California Tracy, California r f E5-9-21x1 , Revised 1.57 f.P.CO•