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�d1j°11� APPLICATION FOR SANITATION PERMIT Permit No.�67;_. (Complete in Duplicate) 1-6- Date Issued __ _ ________________ el� Applica+ion is hereby made to the San Joaquin Local Health District fora permit to c�nstruct and it st 11 the work her i This application is made in compliance with County Ordinance No. 549. t\'nuN ''�'+` r`', ) �5 JOB ADDRESS AND LOCATION.- --------At---------- .'"f_ 4- .-------- ----------------------------------- Owner's-Name- . ------ ---... one --------------------------•---- Address---- .2 f - �'= ' `'` -- �r --- --. .. ------------------------------- Contractor's Name_=_ __ __ - ------- Phone0' � =ll nstallation will'erve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ :. Q Number of Living units: _ _._ Number of bedrooms S___ Number of baths .f____ Lot sizerILQ��.�✓y_-_____________________ Water Supply: Public-system ❑ Community systssn ❑ Private [f--depth.to Water Table ft. r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ . No New Construction: Yes�lo ❑ \l► T • V TYPE OF INSTALLATION AND SPECIFICATIONS: ._ l Se ti �-(No septic tank or cesspool pe rmitted if public;ewer is available within 200 feet.) r s p Tank: Distance from nearest well___74-- Distance from foundation____. .______-Material---____ [ fir No!"of compartmen'ls-------2.-----------rS.ize0,-f- -------Liquid depth____ __.______._Capacity___ Disposal l Field:,' Distance from nearest well_ _ _ ._ Distance from foundation---,�1_�-----Distance to nearest lot �S- - Number of.lines:_-._ _-___ _-_________________Length of each line-----V+ -------------.Width of french___T4Y"__________._____._ Type of filter material___ Depth of filter material---- -.___Total length________ � _ Seepage Pit: Distance to nearest well__ e.5 - __Distance from, foundation_...__ _ Distance to nearest lot r �+.� t �f 'Number of pits_l--.� -----------Lining mate ria Diameter_________________Deptn___.x de t '"1�------------------- F Cesspool: Distance from nearest well_________________Distance from foundation ----------------- Lining material-----_._____--._-._-----_____________ ❑ Size: Diameter- i-------------- ---'-- Depth------------------------:----------•------ ------Liquid Capacity-----------------------------gals. 'ls" Privy:, Distance from nearest well_________________ _ Distance from nearest building ________-. '[]----Distance'to'nearest lot line--------."___- -------------------------------- - Remodeling and/or repairing (describe):------------------ ------------------------------------ --------------- C �.� ----------------•--•-••--------------•------------•-•--------------------------------------------•----------•-- ---------------------•---------------------------------•---------------------------------------- f ` nv : —----------- -------------�-------I---------------------f---------------------------------'---•-----------•^--------------'-•---•------ ------------------- I hereby certify that I 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 Local Health District. (Signed) I ------------------ Contractor ... .. .! W"_ Title)------- --------- -------- ------------- ---------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY .�_ --------------------------------------- DATE - i REVIEWED BY------------------------------------'- ------------------------------------------------------ DATE---------- ----------------�•----- --......_..._ N BUILDINGPERMIT ISSUED ----------------------------------- ----------------------------------------------- DATE--------------------------------------- Alterations and/or recommendations:----------------------------------------------------------------------------------------...----....------------------------------ -- Aj- 1 -----•---------------------•---------------------------•------- --•----•-- -----------------------------------.-_-------------------------------------- •. .........__._...-----•-....-- -----•-•---------------••------- - --------------------- FINAL INSPECTION " Date--"--------------- � ---- ------------------- . SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California FS-9-2M Revised W-2100