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APPLICATION FOR SANITATION PERMIT Permit No.�6 14P. (Complete in Duplicate) Date Issued EiE Applical-ion is hereby made to the San Joaquin Local Health District for Ia permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION '' i x (� ` : Phone:�_--•------------------------- i Owner's Name------------------------C------ •�1_b��_L_�#, �� Address---------------------------------------------------••--•------------------•-------------------------...-----•-i'-'---___---------------•----•--------------�_-----•----------------------- ..----------------•--- Contractor's Name---------------------------------- li one..----.--------- ------.----- - qOumbr - ------------------------ ------- Installation will serve: Residence Apartment Housemmercial ❑ Trailer Court ❑ Motel ❑ Other ❑ living ___ of baths -------- Lot size --------- ---X---Jd-��)------------------------ of Pp Y• Ysystem � p Water Sum ler Public system ❑ Community cyst mm❑ Private Depth to Water Table __*ft. Character of soil to a depth of 3 feet Sand ❑ Gravel ❑ Sandy`Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Ch P Previous Application Made: Yes ❑ No) New Construction: Yes No ❑ i TYPE OF INSTALLATION`AND SPECIFECATIONS: (No septic tank or cesspool permitted if public sewer is available ithin 200 feet.) f Septic Tank: distance from nearest well_ U4____--_Distance from foundation__-_1 _---,___Material_.---_-___ -- -----------=------ �r No. of compartments-____------Z_--_.----size----- __ _ Liquid depths Capacity------ �-- 111 Disp sal Field: Distance from nearest well----3-----.._.Distance from foundation-_____�f�____---Distance-to nearest lot line------- of lines------------- -----------------Length of each-line____-ol _=_O---------Width of trench---------;Y,------------------ T e of filter material_____ i/ -- Depth of filter `aterial------ - `�----_---Total length----------- }_�----------------_ yp !'lZ Seepage Pit: Distance to nearest well--------------- ----Distance from foundation--------------------Distance to nearest lot line----------------- J ❑ Number of pits---------------------Lining material -Size: Diameter------------- --------Depth- - -------------------------- U,1 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------ °Q ❑ Size: Diameter----------------- --------------------r Depth---------------I---- -------=---------------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well--------------------------------- t_-Distance from nearest building---------------------------------------- m ❑ Distance to nearest lot line------------------------------I----------- --------------------------- ------------------------------------------------------------I-------- Remodelingand/or repairing (describe):---------------------------------------------------------------------------•-----------------------------------------------------------------------------�� it.. ro 11 ---------------- 01 ------------------------ l -r - -- --------------------------------------------------------- + I hereby certify that;l have prepared this application and that the?work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Liacal Health District.# (Signed) ---_- Owner and/or ontractorj ------------------ --------------------------- < - -----------------(Title)--------------------------------------------- � i i Y� (Plat plan, s wing size of Eot, location of system m relation to 4 Os, buildings, etc., can be placed on reverse side). J 4 FOR DEPARTMENT USE ONLY 7 `�- DATE ]- 1 APPLICATION ACCEPTED BY---------------------------------------------- - / t,�� REVIEWED BY ------- -1 DATE - 1 -------------- -- BUILDINGPERMIT ISSUED------•- - -------------------- ---- ------ --------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations---------------------------------------------- -----------------------------------------,----------------------................---------- --------- ------------ -------•-------------------- ----------------------------- ----------•----------•------------------ -•---------------•----------•--------------------------------- I ; ---••------------ -------- -----------------I---------------------------------------------------------------------------------•------------------- it -------------------------------- ---------- ----------•-----------------------•-----------•------•----•----------•------------•----------- FINAL INSPECTION BY------------------- .. -------- I Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street p 132 Sycamore Sfreet 014 North "C" Street Stockton, California Lodi, California j Manteca, California Tracy, California �l ES---9-2M Revised W-2100 `