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Permit No.��-l--• --•------ APPLICATION FOR SANITATION PERMIT / 7 (Complete in Duplicate) r Date Issued ------ �{ f - i oa uin Local Health District fore permit to construct and ins#all the work herein described. Application is hereby made to the San .! q This application is made in compliance with County Ordin nce No. 549.,A ------------------------------------------------- - -- --- ------------- JOB ADDRESS AN O TION- '--3 i ... t Phone • -------._ -------------------- �: , . Owner's Name----:---- 11 ------------ ---------- ------------- :. f Address-----•-- -- ---- -- .__�. -_ -- -- - - � -- ------ ------------------ -- Phone.__... ------------------------- ---- -- - 'Contrac#or's Name_____________ "_-- --- ------ Motel ❑ Other ❑ A artmen# House ❑ Commercial ❑ -Trailer Court . installation will serve:. Residence P Q" � ----------------- e��e Number of living units: -- -- Number of bedrooms _ plumber Depth Wa#eoTableJ - ft. Commuriit s stem ❑ private ❑ P . ❑ Water Supply:. Public system y Y Adobe & l±{ardpan Gravel ❑� Sanc�Y Loam❑ Clay Loam ❑ Clay ❑ Character of soil to a depth of 3 feet: Sand ❑ FHA/VA: yes ❑ No k New Construction:., Yes ❑ No, s + Previous Application Made. Yes ❑ No I .-" � TYPE OF INSTALLATION AND SpECiFICATIONs: ` permitted if+public sewer is available- vailable within 200 feet.) p _ Y --- •----- No Septic fa ne ° P p ' � arest'well___._.--"--------Distance from foundation_-_____-""--th =Materia"__--- �--_Capacity----------------- ----- eptic nk: ,. .. Liquid dep• ; No. of compartments Size _ }; q t Len th of each line---- -'-Width of trench ------ ~^ Dis os field: � Distance from nearest well______________-Distance from foundation"_'_______-=:_-""--Distance to neares# o Ene_-__-____________ P _ • Number. of_lines _ g Type of filter material__-`---------- ------R Depth of filter material_-__:--- 0-----:;TD stance length lot line-_;W_ r �= -._. . - `'Distance Pram fo dation_ J "---------------- Seepage Pit. Distance to nearest well � � 2vP.Size: Diameter__..-�-��= Depth "��r Number of pits__--"�------ Lining material _ _. --- V �• Liquid Capacity----------------- gals. Cesspool: Distance from nearest well___"____,________Distance from foundation____- Lining materia___.-------- x ❑ Size: Diameter--------------------- ----------------Depth ---- Distance from nearest.well---- - Distance from nearest building------------------------------------------ 0 ---------"- - - Privy: -----------------------' --------------- - ❑ Distarice'to nearest.lot.line_ - `_ . ----------------- s ----------- ------- Remodeling and/or rep (describe). = ------------- ---------- -------- ----------------•------------------;------ ------- " . ------- ---------------------------------------------- t ----------- --- }. --- ---- ------ "-------------•------------------------------ k-o h - -- -- I hereby certify that I have prepared #his application and'�that the work will be done in accordance with San JoaquinCounty ordinances,here, State favus, and rules and regulation of the San Joaquin Local Health District. Contractor) -- --- - ----- Si ned r Title g =------------------ - _- ------- to wells, [Plot plan, showing size of lot, localfysystem in.relation buildings, etc., can be placed on reverse e. 4 ! FOR DEPARTMENT USE ONLY ----------------------------- DATE------------- ... .. ------------------- APPLICATION ACCEPTED BY----------------------- DATE t . - •---------------------- -•-------- 1 REVIEWED BY--- ------------------------------------------- ----- DATE. ----------=---------------- ------------------------------ BUILDING PERMIT ISSUED _ ---------•-----•------------------------------ -" Al pn and/or rete mendations:____------- ----- " __ _.___. f ---------- ------------------------------------- ------------ --------- -------------------- - --------ti;;�--------- ---------�,� >/' .--------•----------------- _._______. V ________________ Date: = F / FINAL INSPECTION BY +rt- _ SAN JOAQIJIN LOCAL HEALTH DISTRICT S14 North "C" Street t A 132 Sycamore Street 300 West Oak Street Tracy, California 130 South American Street Lodi, California Manteca, California Stockton, California FS-4-2M Revisal 1.57 F.P.CO.