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APPLICATION FOR SANITATION PERMIT Permit No. .-/Q -JI.21. � /� (Complefe in Duplicate) S`s —kG 1� U ��JfJ�� /� ti�� //'_^^L_ .� ' „fJ�n _ � �� Date Issued _�/�_. 3 Application'rs Hereby made to the San Joaquin Local Health District for a permit to construct and install the work h�in criThis applicatiori is made in compliance with Cou ty Ordinance No. 549. �� Sa j JOB ADDRESS AND LO TI N..-- -------� " p .............--- /Y ' �!-- w. Owner's Name-------- --• --�"-Y,- - . ----- ------------ -----••---•---- ----------------•- ------•--- Lo - -t------------- ` . -�--- =-- Phone Address_---- --- ------------- _ C.- �' _ Y'- z -- -------------- Contractor's Name...... f' '�r - f-.. Installation will serve: 'Residence ❑ Apartment House ❑ Commercial Phone------------------------ ❑ Trailer Court ❑ Mot ❑ Other C Number of living units: -`---_ Number of bedrooms ----------Number of baths -- ---_ Lot size .--._ �, Wafer Supply; Public s stem Y ❑ Community system ❑ Private Depth fo . Ater Table'__T_ ft. ' Character of soil to a depth of 3 feet: Sand ❑ ravel E] Sandy Loam Clay Loam ❑ Clay El Adobe El Hardpan ❑ Previous Application Made: Yes (] No New Construction: Yes �o ❑.- FHA/VA: Yes ❑ No E� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic Tank,or`cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from'nearest weIIjDb-�---_ • ce .� Distance fro foundation,lG?-_ „Mat i9i_-- No..of comparfinents___-__- �/ -------------------------- ---yy 5iz , �� 1Liquid depth----- 6 p� ----- ----------t � �.�,•� ------ --- Capacity..] Disposal Field: Distance from nearest well._-Z-�--V--_Distance from foundatio --__ J Number of lined__---��--_- Distance to'nearest lot f Lenpgth of each line -- --- ! Width.of trench-- 2`f___ _ (� Type -- .. f filter material------ - -----------Total len th_-_-_ '�_ Seepage Pit: , Distance to nearest well_________ ______pistanc g T e of {filter meterial_�- Depth o efrom foundation--------------------Distance to nearest lot line.-----_.--.-_--__ ❑ Number of pits` _--- -- - ----Lining material--;. -----------------Size: Diameter-------------------------Depth------------------------------•- cesspool: Distance from nearest well-----------_-.- Distance from foundation--------------------Lining material --------------------------------- ----------------Diameter----;---- Depth'- --------------------------------------------------Liquid Capacity- '..gals. Privy: Distance from nearest well----------------- - " _______ ________Distance from nearest building-------_-_----_--_-< ❑ _pistarace to newest.lot line ------ -- RemodelingdLl and/or repairing (descrilje):`------------------------------------------------ ----------------------------- -•---- -------•----•- ---- ----------------------------- ------------------------------------------------ ------------------------------------•---------------------------------------------------------------------•-------------------------------------------- --- I hereby certify haf I have prepared this application and fha+ the work will be done in accordance wish San Joaquin Coun+y ordinances, State law , d rules nd regulations of the San Joaquin Local Health District. (Signed) , ned}. $ } ------(Owner and/or Contractor Y=,----------- ,--:•----------1------•--------- --- r _ Y. ------------- ---------------------(Title)-------------- (Piot plan, showingsize of lo+ location' of s s+ern in relafion+o wells, buildings, etc., can beplaced on=reveise side). ,t;< DEPA'T1vl NT'U"I'SE ONL , APPLICATION ACCEPTED BY--- ---•- - -----+-- -- ---- ----- DATE---� ._- --- -----� REVIEWED BY-: --- o1 ---------------------•--------- - ---------------- DATE---- -------- --------- -- BUILDING PERMIT ISSUED------------------------- --------- ------------ ---------------------------------------- - -------- DATE---------------------=---- Aitera+ions and/or recommendations:---?------------------ ` ----------------------------------------- --- ---------------------------------------------------------------------------------------- •-------- - ---------------------•-- ----- } --------------------- - FINAL INSPECTION -- . - BY:: . _-- - ' Date _ �f SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Amarican Sfreet300 West Oak Street 132 Sycamore Street 814 North "C" Street Sfock+on, California Lodi, California Manteca, California Tracy, California ES-4-2M Revised 1.57 F.P.CO.