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APPLICATION FOR SANITATION PERMIT Permit No. 77 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 Or nance No. 549, JOB ADDRESS A LO TION Owner's Name---------- . I I . -1- --------------------------------------------------I-------- ------11-------------------------- --------------- ------- -------- - ------------------ Address--------- ------------------- --------------------------------- ----------- Phone-----•------------------- --- -------- -- ----- Contractor's Name -------------------------------------------------------------------;--------------------------- -------- --------------- - ------ - ----------------------------------------------------------------------------------- Installation will serve: Residence [9"Apartment HousL E] Commercial ---------------------- Phone---------------------------------- + Trailer Cou t Z Motel Lj. Other L] Number of living' units: -----,Number,of-bedrooms Number of baths --- Lot size Wafer'Supply: Public', system 6rnhiuri,ify.systern a"U"4-4d--- El Private 0, Depth to Water Table------- ft. Character of roil to a depth 67f 3 feet: Sand [] Gravel E] Sandy Loam 0 Clay Loam ? ❑ Clay ❑ Adobe Previous Application Made: Y' _V Hardpan es El No [jrIll. New Construction: Yes g/N, 0 FHA/VA: Yes El No 0 .4- TYPE:OF INSTALLATION AND SPECIFICATIONS. .(No septic tank or'cesspool perkff;d if pub er s available within 200 fee �c s0iw a- jX§ig Sepfic.,Tank: Distance from nearest i'te --- ---- Ist fr fou afion- Dista c Materi, I N 0;..of cbmpa rtm;ri f s - S;z - ----- ---------- 7 -------- -------- - ------ ----- - --- -------- Liquid V apacify ---- ------------C ie c: Distance from nearest w li;5' 4�ar k Dispos F Ifs ..... . nc. foundation--I4- m 1 0---- . is;ance from 51t - - ---- ---- 190 Number of lines____- ---- ... -----------"Length of each line S f a ri c e to nearest lot line mat 'i I-- ---- eP of filter m ---Width of,trench------ Type of filter eri - a I - - 114- ------------- aferial-------- -e - --------Total length- Seepage Pit" Distance fol-in—ea-rdst'-well" ' - - - - foundation__:"._____`_"__--__. 4- 9 ---------- -----------Distance f rom fc;undaf i - '- El Number 'of pits._-.- on-------------------Distance- 'fo' nearest lot line_____-'________--- -- -- ----------Lining material---------------- ------Size: Diameter-- --------------------Depth---------------------------------- Cesspool: Distance from nearest well-------------------Distance from fou'riclafion-------------------1ining material--------- 0 -- ------------ Size: Diamete!�-- ------------- -------------------- ------------DeFpth Privy: -Licluid Capacity-------------------------- Distance from near'est,well ----------------------------Distance from nearest building-,--------------- El ..p-Distance to nearest lot lire----- ------------------------ ------------I-----------------------7---------:�------------------------ ------------------------------------- ---------------------- ijrn, and/ re F 4* i . Re pairing (describ ---------------------- ------ -------- -- --------- Z A---- .... ...... ----------- - --------- ------------ . ----------------------- ----------- -� - I .. .. - --------e------ - -------I ---------- -- __________________________________- --------- -------------- ------------------------------------------------------------------ ----------------- ---------- ------------------------------------- I ----------------------------*;i----------i----------------------------------- --------------------------------------------------------- -- I hereby certifythat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulationsof the San Jo aq6in Local Health District. (Signed)-la ---- - ----------------------------- ---------- (---------F---------------------------(Owner and/or Contractor) By:-------- ------------------------------------------ --------I----------------------------- ---------------- -------- - (Plot plan, showing size of lot, locationa of system in relation to wells, buildings, etc., ---------------------------------------------- can bele)----------------------------------- placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �A REVIEWED BY N,------------------------------------------------------------------------------------- DATED ------------------- --------------- -- --- ---------------------------------------- BUILDING PERMIT ISSUED...... i--------- - -------------------------- ----- DATE--!;:p-------------------------------- --------------------- ------------------ ----------------------------------------------------------------- DATE--- Alterations and/or re omme daftons: cc7 ------------------------- ------------------------------------------- ---------------- --------------------------------------------- ----------- ----------------- ---------- --- -- ---------- --- -0------ ........ ------ • -------------------------------7---------------------------------- ------------------------------------------------- ----------------------------------------------------------------------------- __ - ---------- ------------------------ ---------- ------------- FINAL INSPECTION-BY.--.-- -- -----------------------:::------------ -------------x Date_ ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American'Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Sfockfon, California Lodi, California Manteca, California Tracy, California ES-1-2M Revised 1.57 F.P.CO. 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