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APPLICATION FC _,SANITATION PERMIT Permit No. __l (Complete in Duplicate) Date Issued ___.___.__.-L- 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 Ordinanc No. 549. JOB ADDRESS AN CATION------- i Owner's Name-------- ;- -- ---- -------------------------------------- ---------------------- ----------' Phone - ---------- Address t_ - -{ ------------£' ----- / Contractor's Name Q- - -- - --- -------------------------------------•--- Phone V/---_,e_ Installation will serve: - Residence ®__Apartment House ❑ Commercial [[�1�,Trailer Court ❑ Motel ❑ Other ❑ / bedrooms _ ,�r e n NOmben+f bed ooms -c:;?--- Number o }bNuppr of livignits: 'athsdI___ Lot size ___�_�__ Water SuI� Public-s stem y ❑itprivate ❑ pepater Tabled .-ff.- Characfer of s611 'to a depth of 3 feet: Sand ❑ ravel ❑ Sar�dy-Loam ❑ Clay Loam ❑ Clay ❑ Adobe�ardpan ❑ Previous Applica�tiont� Made: Yes ❑ -N New Construction-iYes 0 No � FHA/VA: Yes ❑ No ❑ TYPE OF INSTJ#ALLA�TIQN AND SPECIFICATIONS: r' s {No sepfic faW oir'cesspool perm4fed if public sewer is available within 200-feet.) tic nk:_ Dlsta ce from nearest well_________________Distance from foundab n .:_________-___--.Material----__-_____.__.------------------ f ___._ -"-" b .t Disposal Id: Distance f"i•om nearest well ��istance from found at�lq�id depth--------------------------Capacity------__ _-- ------_-- No of compartments------ Ze---------------- - - Det I n_- — ----_____.Distance to nearest lot line-457.11-.___ Number of [.i'nes_______�__________ Length of each line__ '6_�___ __��__-_.Width of french `s Type of filter material-- __ _ Depth of filter materia1____V�---_-----Total length--------------- ------_- - d_f__--- Seepag r : Distance to nearest well__) A.W1 Datanc mtf ndaiion___�7.______.Distance to nearest to Fr 7 Number of pits-----,-------------Lining material . ,- Size: Diameter__-�7�-_-_____-,pepth_.,�Q___________.-__--- Cesspool: Distance from nearest well-----------------Distance from foundation-----1________.____Lining material___.________________________-------- ❑ 5ize: Diameter Depth } r _ -------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well___________________ ------------------------------ Distance from nearest building_____________________ ❑ _ .Distance to nearest lot-line------- Remodelir,rg and/or repairin _[describe):_._.___ { .:__.,l► - ---,-- ---- ----- - ---- fir/-- r - = � .� _ - ----- - - -- ------------------ --- r -------- -- i--f-�------j ! hp reb r+ that I have prepared this applicafionrand that the work will ' one in accordance with S ordinances JoaquGfT County a e law' and r nd regulation of +he San J a uin Local Health District. { {Signed}__ r`__.______._!--- ___ _Owner and/or Contractor) By: -- - ----- --------------------- (Ti#le] = - ---------- ------------ ---------------- (Plot plan, showing size of lot, location of sys in r lation to wells, buildings, etc-, ,an be placed on reverse side). FOR DEOARTMENT USE ONLY APPLICATION ACCEPTED 8Y--------- ------ --------- ---------------------------- DATE--- -- ---- REVIEWED BY-- =' --- ---- - ------ DATE---- !/__ *� BUILDING PERMIT ISSUED---------------------------- -- ---------- -------------------------- DATE----------- --------------------------- A terations and/or recommendations:----------------------- --------------------------------------- ------------- --------------------------- FINAL INSPECTION BY:____ _._ .. . _ -----��-----=-=---------------- � Date-----=--:�-�A �-J-� SAN JOAQUIN'1 OCAL HEALTH-DISTRICT ti t � 130 Soufh American Sfrse+ 300 West Oak 5 eft X 132 Sycamore Sfree4, 814 Nor+h "C" S+ree+ S+ockfon, California Lodi, Cplifornie "'Mpnteca, California �` ' Tracy, California FS-9-2M Revised 1.57 F.RC:0.