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APPLICATION. FOR SANITATION PERMIT Permit No. __A�J7_-- (Complete in Duplicate) / { Date Issued Applica+ion 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. 54''9..! JOB ADDRESS AND LOC ION ---�r_ --------��------- - - ------ - ----�--- 57 = 1 �A- ] i%!1 C'"-------------- Owner's Name-------------------/------•-•--------------... - ••------ ---- - -' ----------------------------- -------------- Phone--- ----------------•--------------- Address------------------------- ►4-�-,tr/ �-------------------------------------------------------------------------------------------------------------- Contractor's Name---------------------------------------------------------------------------------------------------------------------------------------------- Phone--------------------------------- Installation -- ----Installation will serve: Residence ❑ Apartment House ❑ Commercialf Trailer Court ❑ Motel ❑ Other ❑ -' Number of living units: ------- Number of bedrooms-: Number of baths .:�4_ Lot size _____________ ---------------_---------- Water Supply: Public systema❑ Community system ❑ Private)' D�pth to Water Table ________ ft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe. Hardpan ❑ E Previous Application Made: Yes ❑ No [• New Construction: YesA No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Y r 4,,:(Nosapt� i enk_or cesspool_permitted if public_sewerjs available,within 200 feet.) Septic Tank: Distance from nearest well --------Distanc rom n founcion__�-______-Material____'___ ____ _____ ___ _ � No. of compartments--------- �---Liquid depth_------ " __-_Capacity--_lr��_-_-- Diolline Field: -Distance from nearest well____-__Distance from foundation___16 --__._.Distance to nearest lot line____�. Number of lines_______ -___---___ ____ Length of each line:________`"T Width of trench---------- .r� f Type of filter material-__0'__ _ __- epth of filter material___-____�+~5',_{._Total length------------ _________ 4 Seepage Pit: Distance to nearest well------------------_---Distance from foundation__________________ Distance to nearest lot line____-_--_________ c ❑ Number of pits--_ -------Lining material---------------------- Diameter-----------------------Depth___----________-________-______ Cesspool: Distance from.nearest well----------------- from foundation-------w...........Lining material_---------------------------------- Priv Distance prom nearest well __ _--Size: Diameter---------------------------- ------- 1Depth J--------------------------------------------------Liquid Capacity----------------------------gals. '_ Y= f r ----- ------------------Distance from nearest building------------- -------------------------- ❑ Distance to nearest lot line-----------------r -------------------------------------------------- Remo eliing and/or repairing (describe):__4�...r __.. ______ .�. ------------ -------------------•-----•-----------------------------------•--------•--------------------------- i I hereby certify that I have pr are +his a ica+ion and that th work will be�dane in accordance with n Joa uin Cou g q refy ordinances, State laws, and rules and ulatio s of,the San Joaquin Ldcal Health District. (Signed).... --_:_-- -__ ` ---------------- ---- ---------------- --------------------------------------------------------------=--------(Owner and/or Contractor) ------------------==----------------------------------------------------- ------ --------------------------------•---•-- .(Title)---------------------------------------- ----- --------------- (Plat plan, show'mg`size of lot, loca+ian of system in relafiofto-wells,ybuifdirigs, a+c., can berplaced on,reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - -- ---------------------------- = DATE 9 f �5� REVIEWEDBY------------------------------------- -- - - ------------ -------------- --------------------------------------------------- DATE-----------------------------------... BUILDING PERMIT ISSUED,----------------------------------------------------------------------------------------------------- DATE------------------------------ Alterations and/or recommendations--------------------------- --- ----- - - -- --------_---------------------------------•----•------------___----------------------------------------------- -------------------------------•----------------------------•----------• • --- ----------------------------- -----------------------------•--•--------------------•-- -------------------------------------................... a ---------- ----------------------------------------------------------------- ----- --------------------------- ------------•-----------------------------------•-• --------------------•--------------------•---------•--- ------------------------------•------------ ------ - .-- . --------------------------------------------------- ---R.- - - ----- I=fNAL INSPECTION BY:- - ------ ----------- Date -- _ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ;. 300 West Oat; Street 132 Sycamore Street 814 North "C" Street Stook+on, Californ a Lodi, California Manteca, California- Tracy, California ES-9-2M 145446 ATwnno 12.54 .. f