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144 APPLICATION FOR SANITATION PERMIT Permit No. .Ag_y. -...., (Complete in Duplicate) .� .b '�� Date Issued ----- ---._ k Tulica+ion is hereby made to the San Joaquin Local Health District for a permit to construct nst�"I[We-WbrP-herein described. This application is made in compliance with County Or finance No. S f ; JOB ADDRESSPALOCAT N--..- --- ....... ___----- 1 - --- ------------------------ •---Owner's Name-- ---------------- ---------- --------------------- --- --------------- Phone�s .�,,.2J!� Address � 2. ----------- ---------------------------•------------------------- , Contractor's Name-----.---.. Phone �� kk Installaflon will serve: Residence(, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ F.. 1VII l,er ..f 1,..:.,-.,,„:+'. /� __I.�,.._L--°-f - installation wiserve: r Residence MotelA❑ rt Other se ] ,Commercial's<s giler`Court ❑ f _ _ __ 3 ..,. .... ..K _ P t.Aairacter of soil to?adepth sof 3'teet:"Sand ❑ Gravel ❑` Sandy Loam ❑ Clay Loam p Clay ❑ Adob� Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ ` TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or cesspool permitted if public,sewer is available within 200 feet.) Y Septic Tank: Distance from nearest well--- -. Distance from /foL undaft ion._ _t____.Ma�teriaL�' C`=paci Liquid depth.--�-No. of compartments--- -------------Siz - t,►' -r ' f f Dispos I Field: Distance from nearest well_-.� _ Distance from foundation./CJ...-----._,distance to nearest lot line--__-----.._.. Number of lines..... .................. .....Length of each line-.__----1.e t -------------- Type T e of filter materia! r Width of french ---------•--- yp -:--•Depth of filter material--- -----_------Total length---.------e4p-------------------- Seepage -----------------Seepage Pit: Distance to nearest well---------------- ----=-Distance from foundation--7"------------- Distance to nearest lot line..------___-__--_ ❑ Number of pits----------------------Lining mateiial-----------------------Sizer Dia meter-----------------------Depth----. ( Cesspool: Distance from nearest well-----------------Distance from foundation._-.----- _--------Lining material-__...-------.---_-.-_------_-------. Size: Diameter----- ---r--------------- -----------Depth--------------------------------i--- Liquid Capacity gals. ► Privy: Distance from nearest well.-.;__----------------------------------------.-Distance from nearest building_---_-----__.----__----._ - --------------- ❑ Distance'to nearest lot line----------=---------- --------------------------- I Remodeling and/or repairing (describe) -11' ----------------------------------------------------------------------------------------------- --------------------------- -----•------------•--------------•-----•-------.-.--•--•------•---- ------------ ----------------------------•----------------------------------------------------------- --------- ------ ----------------------------- ----------------------------------•- ---------------------•-----------------------••-------------------• -------------------------------------- --------------- 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, alot, locaji-0-n regulations of the San Joaquin Local Health District. i (Signed) ---------------------------------------- ------------------------------------------------------------------- --(Owner and/or Contractor) By: - • --�--••-----------------:------ - -----------------------• ------9------------------(Title)---- - ---- (Plot plan, showings a of system in relation to wells, buildings, etc., can be aced reverse side). ` FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- DATE---- REVIEWED BY rj ---- ---------------------------------------- ---------------- DATE---- # S------------------------- BUILDING PERMIT ISSUED-------------- - -------- - --------------- --------------------------------- ------ DATE----- - -----------------•- M Alterations and/or recommendations:------------------ ---------------=---------- == ----------- ------- --------- -------•--•--•- ------------------------------------------------------- -- FINAL INSPECTION BY:.----- >: ----- Date----------- -- --P .- - . SAN - .-. JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California es-9�zM 145446 ATWnnn IZ-54