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FOR OFFICE USE: <------------------------------ --- ----------------- r~ ___- -._-------- ----------- ------------------------ -- APPLICATION FOR SANITATION PERMIT Permit No. J� .' - ------------------- -- _.. (Complete in Duplicate) - -- -------------------------- .r This Permit Expires 1 Year From Date Issued Date Issued ` Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descried. I This application is made..in-ca Zp fiance with County Ordinance No. 549. &,,OA) ti 2_,u_5 —fnG--CDS jFSG JOB ADDRESS AND.LOC ION. � ------ 14 uts f-----_A_V -------------------------- Owner's ----------------------- Owner's Name - � 1- ------------------------------------------------------ Phone----------------------------------- Address------------ -------------------Address------------RTE--`.....- ------ --•-- px---- /2.,7 ------------E5C_ A�A ..' Contractor's Name--•-QiC11 ---------•----------------------------------------- --------------------------------------------- Phone----- ---- Installation will serve: Residence ®' Apartment-House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. __ _ Number of bedrooms �_- Number of baths ---1-- Lot size ---AC-I IFPG-X�---_----_-----_------- Water Supply: Public system ❑ aCommunity system ❑ Private Depth to Water Tablea f. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam F1Clay ElAdobe F1 Ha I Previous Application Made: (If yes,date---------- ------y No [[ New Construction: Yes Er<, ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: �. -- '(No septic tank or cesspo91-permitted if pu� sewer_is available,within_200 feet..)_ -- Septic Tank: DisNo. nce from nearest ofcom artments_W � -:___.._.__Dzea XrO Xfoundation--Liquid®pth__Material Ie ---�-Np 0____. Number of lines----------- ---------------------Length of each line----/QO--`----��__---Width of trench....... -f -------- --- Dis osal Field: Distance from nearest well.-..��-----Distance from foundation-----IV- _____._.Distance to nearest lot line---- t I w Type of filter material---J �]C/ �___Depth of filter material------�_�.. --- Total length---------------AVO____-_________. Seepage Pit: Distance to nearest well_--------------------Distance from foundation--------------------Distance to nearest lot line_.___-__--__.-._ �I ❑ Number of pits----------------------Lining material---------- -----------.Size: Diameter------------------ ----Depth------ -- - ----- - ------------- Cesspool: Distance from nearest well----------_------Distance from foundation------------.------.Lining material____...__.______....____________._._. C Size: Diameter-------$ -----------------------De th--------- ---------------------------------- -----Liquid Capacity-. gals. Privy: Distance from nearest well_______________________________________-__.___Distance from nearest building.......---------..-.--_-_-_---------_..._. 4 ❑ Distance to nearest lot line----------- i---------=----------------------- ------------------------------------------------------------------------------ ---------------- Remodeling and/or repairing {describe):------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------- ---------------------------------------------------------------------`---------------------------------------=--------------------------------------------------- --------------------------------------------------:---------- ------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------- 1 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)----7�2-----/--� / ---------------------------------------- -------- --------------- -------- -----------------------------------(Owner and/or Contractor) �-, -- ABY:-- . ter _ ----= :_ _ = ----- -------------------------------------------------(Title)---- ---- ------------------------------------------------------ (Plot plan, showing size of to , location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY i - APPLICATION ACCEPTED;BY. ` R •------------------------------------------------------------------------ DATE.----- --------- ----------- REVIEWEDBY-------------------------------------------------------- --------- ----------------------------------------------------------- DATE-----------------------------------_------------------ BUILDINGPERMIT ISSUED-----=---------------------------------------------I------------------------------------------------._ DATE.------------------------- ---------------------------- Alterations and/or recommendations--------------y------ - : "-- - ------------------------------ ------- (.. -- -- --- ------------- ------------------- - ------ - ---------------- -- --- ---------------------------------- •----------------------------------•---------------------------------------- FINAL INSPECTI �lEQ- -- Date------------- ..:_C C� _- ---- -- --------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi;California y r Manteca,California Tracy,California