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APPLICATION FOR SANITATION PERMIT Permit No. __.1. ._. (Complete in Duplicate) This Permit Exfres i Year From Date Issued Application is hereby made to the San Joaquin Lacal Health D Date Issued _`//_C//L This application is made in compliance with County O dinance'Noc549r a r 4` e "work h ?_ p it fi onstruct and install the work herein described. k JOB ADDRESS AND L CATION•_. Owner's Name_-___ :�'`""!� - p �Wt------------------- Address---------------� U --------------------- ------ -- Phone.----Contractor s Name- ---------------- ------- =`-- `- ---------------------------------- Phone.. Installation will serve: Residence E?'Apartmen# House ❑ Commercial Number of living units. __`,- Number of b ❑i Trailer Court ❑ Motel ❑ Other ❑ bedrooms Number of baths _- -- Lot size o Water Supply: Public system el,_Communit system ff. Y Y ❑ Private ❑ Dep#h,to Water Table .� ft. Character of soll to a depth of 3 feet: Sand Gravel E =Sandy Loam ❑ Clay Loam I Previous Applicatibn Made: Yes ❑ No r Y ❑ Clay [] Adobe❑ Hardpan ❑ �° NewLConstruction; Yes, ErNo ❑ FHA/VA; Yes R��No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:- - No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic Tank: P Distance from nearest well__._"^----Distance from foundation_ __/ ' No. of compartments"--"-_ -------Material--.- Size__ ^� * ,x __-- Liquid depth----- sI—'- --------Ca acit --- Disposal Field: Distance from nearest well___-_^---"-_._M0an ' from foundation_ p Y � ___.__Distance to neares�ot line___- -� Number ofdlines______._ _-" -------Length of each line_____ Type of filter material: p Width of trench.__ Depth of filter materia__ ----------------- - ii Seepage Pit: Distance to nearest well_______________ _ _Distance from foundation"-1�• --Total length--_-___-�',�� ---_-_- y. -- , Distance to nearest lot line________________ Number of pits"--------------------Lining mafierieil -: ! Cesspool: "Size: Dib`mee}er. ..:- ------Depth------ P Distance from nearest D i Distance from foundation--------------------Lining material ------------------------------ -----------------------❑ Size: Diameter------------------ ---- --- ------Depth- --- ---- 'Privy: Distance from nearest well------:--- "-_---- ------------ Liquid Capacity--------------- --gals, __ ---- ❑ Distance to nearest ]of line------- -------Distance from nearest building__--_--_---_-__ �. ------------------------------- ------------- - ------------- Remodeling andori repairing_[describe4:------- --- ---------------------------------------------------------------------- ----- -------------- - --- ----- - ------------------------------ ---- ---------- -------------- � _p - s ---------------------- --- ate:. ------------------------------------------------------- ordinances, State laws, and rules and reg I hereby certify that I have'prepared this application and that the work will be done in accordance with San J aons of the San Jbaquin Local Health District, aaquin Coyr�ty ti ` (Signed)-.---------- . -------------- jin -- -- - - ----- Apr- ----- ---- ------------------------------- ----------•--------------------••--•--. CO r car) a,.#� ,:_ - --(Title)-- -- (Plot plan, showing size of lot, location of systeion +o wells, buildings, etc., can be placed on reverse- Side). •. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-..____ _ .U REVIEWED $Y--- -------------------- DATE--- ----� `l t<?_Q - ------------------------ -- BUILDING PERMIT ISSUED DATE -------------------------------------------------- --------------------------------------------------------------------- --------------------------------------------------- Alterations and/or recommendations: " ----------------- DATE-------------------- ----------------- --------------------------- ------------- {p -.---"------------- FINAL INSPECTION BY:..--..._._. V --- -------- ----- Date------ SAN -- --SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street—14 aflo"r,. f ` , 132 Sycamore Street 814 North "C" Street Stockton, California Lodi California 4 .+v a Manteca, California �r Tracy, California ES-9-2M Revised 0.'59.F.P.Co.