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APPLICATION FOR SANITATION PERMIT Permit No. ---3AI (Complete in Duplicate) Date Issued ----- Application pplication 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. 549. JOB ADDRESS AND LOCATION__ � h -------------------------------------------------------- -------- Owner's Name---- - .eY --------------------------------------------------------- ----- Phone------------------------------------ Address------ ------------------ -------------------------------------------------- Contractor's Name P -- --------------------------------------------------------- -- Y-- -- ----------------- Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ �ai r , ur Motel Other ❑ Number of living units: __ Number of bedrooms Number of ba _ ___►L size ______--. �__(A_ __,l1__ 4,R______________________ 21 Water Supply: Public system ❑ Community system ❑ Private, ' D p o ,ter ab e _ __ ft. Character of soil to a depth of 3 feet Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay.❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction. Yes IN6,.,,No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: ,(No septic tank or'cesspool permitted if public sewer is available within 200 feet.) n Distance from :from foundation__. Material___ ---------- 0;A'15 ❑ No. of compartments------ ------ Liquid depth Capacity Size_ Disposal Field: Distance from nearest well_._)d------Distance from found ti ion___ Distance to nearest lot line__5 ________ Number of lines_'` __________Length of each lineY'_- __ -Z,.'�_'_ `� ..Width of trench------ Type of filter materia] _l _I' �C__Depth of filter material___1__�___________Total length-----IF___________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation___----------------_Distance to nearest lot line----------------- El Number of pits.-._i-----------------Lining material---------------------.-Size: Diameter-----------------------Depth----------------------------- - Cesspool: Distance from nearest weli-----------------Distance from foundation------------------- Lining material_ _-_____________________- ❑ -_ __ - ti—-- - -_ _ -g --._� _ Size: Diameter-------------------------------- - Depth----- -- -------- -- - Liquid Capacity-;---------_�------- - -ga s. M. 4. Privy: Distance from nearest well________________________________________________Distance from nearest b "!ding_ ------____ Distance to nearest lot lineRs.fir_- Remodeling an /or repairin (des 'l3 - _- 'c ------------- ----- -------------------- -- -- m---- .�O''`— ----- - -- - ------ ---------------- -- ----- -• ---- --- .rfit-� -- I hereby certify that I have prepared this app ica -on and fhatIse wor wie o an oaquinGun y ordinances, State laws, and rwles and regulations of the San Joaquin Local Health District. ( e l /or Co rat or) (Signed) --�- ----------- --------- ------ ---- l tl .f� .. BY•--------------------•------------------------------------------------- - ie (Plot plan, showing sire of lot, location of system in relation to ells, buildings, efc., can be placed o reverse si e)j ` FOR DEPARTMENT USE ONLY W '' APPLICATION ACCEPTED BY---------- -----------------•----------------------------- --------------------------------------- DATE------------------------------------------------------------ -----------------------------------BY------------------------------------- ------------------ DATE — ------------------------------- BUILDING PERMIT ISSUED--------------------------------- - DATE--------------------------------- a '�..- Alterations and/or recommend ationsi1-------=------------- ------------- -------------------------------------•-•----------------------------------- ---------------- ---• ---- 'I ------------------------------------ ---° --- .....---------------------------•----------------•--•-------------------- z ---------- ------------------------------------------------------------------------------------------------------------------------------ ------------------------------ ------ ---- --- FINAL INSPECTION BY----------- ----`---- ------------------- ------ Date------------- —` SAN JOAQUIN LOCAL HEALTH DISTRICT ; 130 South American Street 1 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California I Lodi, California Manteca, California Tracy, California ES-9-2M - Revised 1-57 F.P.CO. C