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1`� L APPLICATION FOR SANITATION PERMIT Permit No. _111X7 (Complete in Duplicate} r� f r bate Issued r Application is hereby made to the San Joaquin Local Health District fora This application is made in compliance with County Ord-mance•N 549,. permit to construct artd instal! the work herein described. JOB ADDRESS AND--/ = ---LOCATION_• _ ------------------------------------------ Owner's Name------ ell---- t A ' ----------------------------------------- Phone-----•------------------ Address--------•------ -- ��JJy'y'11�/x ~----- ----�----------------------�---- 7/" {Contractor's Name - ------------ _____ ,�, -,� Phone-------- Installation will serve: Residence c - apartment House ❑ Commercial ❑ Trailer Court - , - ❑ Motel ❑ Other ❑ Number of living units: f Number of bedrooms ----/. Number obaths _ ' ! Nbf 1 ,Lot size -- -`' ------------------ Wafer Supply: Public system ❑ Community,, ystem p Private p Depth to Wafter Table -�``` ft. Character of soil to a depth of 3 feet: Sand ❑F Gravel [] Sand Loam.. Cla "Loam Clay i Y ,— Y Y ❑ y ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No O'�Ne'w Con'structioi�Yes No- ,❑ - SHA/VA: Yes ❑ No:[�qr i TYPE OF INSTALLATION AND SPECIFICATIONS: '"`' (No septic tank or'cesspool permitted if public serve sl ilabf��vithip 200 feet-) ' .--.Dist ice from foundationMateria!- Septic Tank: Distance from nearest well_ ____ -- r -at No. of compartments---- ------------ --Size__i� -, - .---Liquid depfli!_// / - -------------- ----Capacity-----�---��- -- -Pisporyffl Fields Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line----_----_---_-_. Number of lines---------------------------------- Length of each line------------------------------Width of trench---------- ---------- - Type of fitter material-------------------------Depth of filter material.-�-------------------- length_____-_________--_______ -------- eelSage Pita Distance to nearest well_____________---_____Distance from foundation'______________ Distance to nearest lot line Xr�T�� Distance f o tsne-----------------Lining material----------------------Size: Diameter----------------------- Number --- -----Depth------ ------------------------ Cesspool. crest well-----------------Distance from foundation- .-"j___-_---_-_.Lining material___.--_--_____.-__-_-------------- ❑ Size: Diameter------------------------------------De Depth - ------ � ,Y -------- �-------Liquid Capacity---------------------------gals. Privy: Distance from nearest well_______--______---------- --------- -- -Distance from-nearest building -- --- Distance to nearest lotline_______________________________ __ ----- --- ------- - Z ------- --- - ---------- Remodeling and/or repairing (c�escnbej--------------- - ✓ 6 - -- -- -- - ------ ------------------------- ------------------------- ` ----=--------•--- -------------------•---------------------------------------- ------------------------------------------------------------- ------------------------------------------------------------ -,----- 411 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, d rules and r ulations of the San Joaquin Local Health District, Y • -�..-Tom,-._....._.. . 5i ned - - ------------------------------------------------------- -------I ti= ; ( Owner and/or Contractor) '} Y: ----•------ -------Title)-------------------- . - - ---- -- - ----------------------------------------- _ ________ 7 ----------------------------- -- (Plof plan, showing size t, locatiod of system in relation to wells, buildings, etc., can be placed on reverse side). # FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__________ _______ , DATE -------- REVIEWED BY------ --------------------------- ---�- -: ��- 4- ----------•------------------- - UILDING PERMIT ISSUED------------------' - -------------- -------- DATE--------t ------- ----------- DATE--------------- -------------- - Alterations and/or recommendations:_______ - ------------- ------------ ---• ------- -- ---------------------------------------------- ----------------------------------- ------- FINAL INSPECTION BY: Date S/ ------- fi ----------- - ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Stree+ ��'� ' 300 Wesfi Oak 5+reefi, !32 Sycamore'$free+ 814 North "C" Street Sfock+on, California Lodi, California Manfeca, California Tracy, California ES-4-2M , Revised 1-57 F-P.CO.