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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in, Duplicate) � 4 �� 0 Date Issued /�A y Application is hereby made to the San Joaquin Local Health District for a permit to construct and install t e ork 49rein described. -- This application is made in compliance with County Ordinance No. 5499.. D _. JOB ADDRESS AND L TION_ �Vf , i� /i ` G Owner's Name -- --------------------------------- ' one. 3f t Address ---------- ------ ---------- .actor's Name'._..- --- _ ----�-..... ._.---------- ------ --------- -------------------------------------------- _ Phone- -----:� I. Ination will serve: Residence Apart ent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms_. Number of baths _ Lot side ___v _-__4'�.- Water Supply: Public system ❑ Community system ❑ Private , Depth to Water Tab'1e.1�'ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe Hardpan Previous Application Made: Yes ❑ NNew Construction: Yes No ❑ FHA/VA Yes ❑ N TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic rank or'cesspool permitted if public sewer is available within 200 feet.) UposalF Distance from nearest well______ _. ____Distanoe from foundation__._-__ __-_-..Material--------------------------__------------------- No. --__-______ ____. No. of compartments--------------------------Size------------------------•------Liquid depth-j------------------------Capacity------------•---------- Distanc rom nearest we;- .--- _____Distance from foundation__________________IDistance to nearest lot line-__--___-_______- Number;of lines___-___•--_-_.-------------------Len Length of each line____________ ______________ Width of trench } ________________ Type of?filter material._______________ g F yp Depth of filter material_____________ ____ Total length__+LL� _._.____.__-___________ ..__ t p Distance to nearest I t line____ ___._ See a e Pif: Distance;to nearest well___9l�_____._Distance from f dation -._ Number<of pits ----/------------Lining material -� .-------Depth----_5--- -------- _____Size: Di etar____. i C sspool: -Distance from nearest well-----------------Distance from foundation ¢ Linijmate rial '__ ______________--------- Ca ❑ Size: Diameter--------------------------------------Depth --- ------------------- ----Li uiacitY gals.-�rivY Distance4 from nearest well____ _____________Distance from nearest building _ ----------- ------------------------- Distance - - --------- -- --- t ❑ Distance to nearest lot line---- - --- -- ------------------------------ -------------- -- ---- ------------ ---- -- a - j Remodelin a or irin (descri e�:___,- , y __________________________________ _________�______._.____ ...___..... .....................`._..__._-__________---____• ` -. ______ ______________________ ____________________________________________________________ _.__-_- -_______ ______-----------_--------. _____ ________ _________ _ _________ hereby certify that 1 have prep ed this application a ' t1ia fide`ork'will be done m accordance wifFi'ian' oa ounty ordin es to la s,,and rul an r ulations he S Joaquin cal Health Di 'cf. f '' �______ ` _ ner a or Contra mor (Signed) = ---- ------ ) By: ------------------ ------- -:�. ......� --------------------------------- / ---.----------- (Plot plan, showing size oftbt, Iota on of system n r ation to wellss,I 'gs, etc., can be p ed on re erse e). P DEPARTMENT USE ONLY APPU N Ai D BY �-`----------------------------------------------------------- DATE -----------------7- REVIE ED ----- ------- --------- --- --------- --------•--•--------------------------------------------- DATE............................................. --------------- 1, BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----------------- ------- - - Alterations and/or recommendations:____ ___________ -__-_ ____-_--,�_________--_-___-__--__. -------------------------------------- --------------- -- jr-----P ---------�-5-----------O.A<---------------------------------------------------------------------••-------- 17 d Tt-C?1±►r ------------ --- - I ------ ----------- - ------ - ---------------------------------------------------------------------------------------------------------- ------------------------------------------------- ---••--- ----------------- --- ----- FINAL INSP4C •----------------------- - Date--------6n.--3------- 1 � J SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South `'arriean Street 300 West Oak Street 132 Sycamore Street 814 North "C' Street Stock�synj Qalifornia Lodi, California Manteca, California Tracy, California ES-9—�M , '. Revised 1.57 F.P.CO.