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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date..lssued -3--- 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 LOCATI N_ _F3S -56 X, - .--- - ----- fl.,..--" J Owner's Name--------- = h_f I l l Y` -e v Address ----------------------------------------- ----------------- Phone--- -- --0- --3V-•-t- ----------------- - Contractor's Name ----------- --- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____ Number of bedrooms I___ Number of baths /____ Lot size ----457�-�--�-�_. ----------------------- Water Supply: Public system .❑ Community system E]Private Depth to Water Table L�� ft, t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑, Adobe Hardpan E]W Previous Application Made: Yes No E] New Construction: Yes No)<' FHA/VA: Yes ElNo El TYPE OF INSTALLATION AND SPECIFICATIONS:' (No septic tank or' cesspool permitted if public sewer is available within 200 feet.) a Setic �an : Distance from nearest well-, ---------------- Distance from foundation -------------------- Material-_______..._ - -- -------- - --- ❑ No. of comparfiments-------- -Size---------------- Li Liquid de th------------------ --------Ca acit p r q gip.P y---------- Di poral Field: Distance from nearest we4_- � Q --------.Distance from foundation___ ?"0______ '----------- Number ' .__-_Distance to nearest lot line___-_________ Number of lines ---------/ ------.------------------ Length of each line -------- too _�-------,. --.Width of french ---- .� _�t__--------- E ------ Type of filter material___ - ------ ______ Depth of filter material_______7otal length-------------------------- ED --------- Seepage ____________ ________ ___ED__ -"-"--- Seepage Pit: Distance to nearest well ---------------------- Distance from foundation -------- _---------- _Distance to nearest lot line .... -______.----- ❑ Number of pits_-�------------------ Lining material ----------------------- Size: Diameter -----------------------Depth---------------------------- Cesspool: Distance} from m nearest well_____________.__Distance from foundation ___________________Lining material -------------- , .�, ❑ -- Size: Diameter---------------------,-------------Depth--------:-------------------------------------------Liquid Capacity -.--------------------------gals. PPriv I rivy: Disfance, from, nearest, well --------------------- ___------------------------- Distance from nearest building ❑ Distance to nearest lot line_ ' ._,-------_-_----_____ --T •--------- ----------------------- or ter pairing des ibe :___._ein and/Remod ---------t---- - --- =� w - ----- ----------------------- �_ __ - ____ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin"County ordinances, Sf* law and rules and r g ons of the S Joaquin Local Health District. L, (Si ned `: � � g ---. -, - :: ------- ---------- L---'-=----------------------------------------------------------(Owner and/or Contractorj By:---------------- - ` Title 1 % ( }-------------------- --;--- --- ------------- P of plan. showing size of lot, location of system in .relation to wells, buildings,'etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY O 4 APPLICATION ACCEPTED BY ------ &c-':pATE-------`._�___`_-------- - ------------------ E REVIEWED BY -'-- -- ------ BATE ----------- ------------------------------- BLIfLDING PERMIT ISSUED ----------------- I------------------------------------------------------------------------------- DATE ----------------------- ----------- ------------------------- A Cera#ions and or recommendations:-�_____._____________________.__ - ._. ��. ----------- ----------- --------------------------- -------------------------•------------------------•------------------------------------ i' ___________ ______ _-------------------------- _ --- ---------- ____________ __ ________ \ __________________________ _3f-_ s_ ____'__ -------- � --- ------------ ________--_-_-F--___�___.___ _`-7 _ ________________ _ r..,.;�-..------------- FINAL INSPECTION BY: ------------ .---------------------------------------------------- Dc r �2-'� i Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Sforkton, California Lodi, California Manteca, California Tracy, California ES -9-2M , Revised 1.57 FRCO.