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APPLICATION FOR SANITATION PERMIT Permit No. ___ _7`f`------ I (Complete in Duplicate) D ate Issued __�"""""------------- Application Is hereby made to the San Joaquin Local Health District for a permit to construct and install the worn her,{'yn�lsced. ' This application is made in compliance with Cou ty Ordinance No. 549. pRG'� �I KESS A LOCATION -- - j 1 JOB ADD .��'�1�1----Yll��`,��_ ��---��._�f_�._�It,__��`ff---"------------------ Owner's Name - ---1-•- --.--------A/Q�116-- ----- n - ------ Phone----------------•--------------_---- -------------------- - ------------- --- Address_.... !_ B --- - +r�I' �•,A- I�lll ��1� Ire Contractors Name______.. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:LW-Number of 6edroomsN umber of baths I----- Lot size �JQ------------------------- r Water Supply: Public system ❑ Community system '❑ Private x Depth to Water Table-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ l Previous Application Made: Yes ❑ No New Construction: Yes ❑ No i PE OF INSTALLATION AND SPECIFICATIONS: TY m (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r �a 7 Material-_4_C_h/---------------" Se ti Tank: Distance from nearest we(_ _"_____Distance from founda#ion_ __" _ -- j e (v_ _ _ Liquid depth-S.Z__r_._____ _Capacity- No, a acit � _� _/•� No- of compartments-- -D--___----Siz - --____-- ' +- qP Y ! �"_ ____Distance to nearest lot lir,e__�f Disposal Field: Distance from nearest well___{�0______Distance from foundation r - �� ---"'---�� Number of lines___6�1_�__l._._ ---___Length of each line___ Width of trench_ � ;-------------- Type of filter material,1/X"9V0��---Depth of filter material___ ___________Total length____ _s ---------------------- y Seepage Pit: Distance to nearest well____________________"Distance from foundation-------------------- to nearest [of line______-__________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter Depth Cesspool: Distance from nearest well---_-------------Distance from foundation--------------------Lining materia tT ❑ Size: Diameter-------------------------- ----------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ F1 Distance to nearest lot line---------------- - ------------------------------------------------- ,, / / r ----------- Remodeling and/or repairing (describe):__ -___ 1__-- -- - 'L/--- --------------------------------------------------------------- ------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepar, this application and that the work will be done in accordance with San Joaquin County f" ordinances, a laws, and rules and_re Va+ions�Jof the San Joaqu' Local lth District. rVti I o1 t.(Ow e c [Signed ---- = _ � n r_. dor Co1�tr fork - ' 13 ' [Title) Y•-- � (Plot plan, showing size ot, location of system in relation wells, buildings, efc., can be pl�a4A on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ' DATE--------------------- £" -------------- DATE---- ------------ -- �----- - -- --------------- REVIEWEDBY-------•----- ------------------•-------- - --- --- -- -------- ------------- -------------- --------------- �• BUILDING PERMIT ISSUED -------- DATE Alterations and/or recommendations---------------- ----------- ------------------------------------------------------------------------- -------------------------------------------------- ------------------------------------------------------- ----------------------------- -------------------------- ------------------------- --------------------------------------- FINAL INSPECTION BY: ]� Y Date-------- 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100