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1-UK UI-HU 1151:: ----------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. �Y.2 ------------ ------------------------------------------- (Complete in Duplicate) -------------- 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 themork herein described. This application is made in com I' nce with County Ordinance No. 549. /MCA JOB ADDRESS AND OCAT o--------0�_)/------/20 RT F -- OF COTTAC _ }V' - P-� _ K- ---------------�U6-19.K-------- --------------------------------------C�Owner's Name-------- - Ph Address-------••------ -- Contractor's Name ----------- ----- ----------------------- ------------------------------------•------------•---•- --- Phone----------------------------------- Installation will serve: Residence [_] Apartment House ❑ Commercial railer Court ❑ Motel ❑ Other ❑ SHOP Number of living units: ___ Number of bedrooms - Number of baths-__ Lot size ----l'_4k�_ }- ----------- ------ Water Supply: Public system ❑ Com ntity system Private;Depth to Water Table A-0- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy.Loam ❑ Clay Loam ❑ Clay [❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date_ . ----------) No [—'_'New Construction: Yes �No ❑ FHA/VA: Yes ❑ No T1s TYPE OF INSTALLATION AND SPECIFICATIONS: -F(No-septic tank'or-cesspool--permit#ediif,public sewer.is available-within-'200-.feet:]'"' Se tic Tank: Distance from nearesf well--_S ---Distance from foundation---&---------Materi l---_Cv. ,t] No. of com artments__�__1--------------Size__. _ s ._ Liquid depth - ------Capacityad Dis osal Field: Distance from nearest we!__..�___-.___Distan�ce,f� foundation.,Jly-- • � {�- p.: �� ---- ______ p �Q -.- --------Distance to nearest lot line_ Number of limes-______..__1__ _ _________________Length of each line----- - Width of trench.--_-_--- ,�� Type of Vfer�material. --1_ Com-_Depth of filter material-_._j__ ----------- otal length----------------- 0---- .------ Seepage Pit: Distance to nearest well-_---_____--_----____Distance from foundation__-__-----_-__--.Distance to nearest lot line_________________ ❑ Number of pits----------- ---. ---Lining material-----------------------Size: Diameter_---------1 -- ----Depth--------------------------------- '� Cesspool: Distance fromnearest well-----------------Distance from foundation....--------------..Lining material-----------.--..-----__----.__----.__. E ❑ Size: Diameter-14�-------------------------------------Depth-------------------------- Liquid Capacity gals. Privy: Distance fro'nearest well---------------- ____--__---Distance from nearest building -----------. ❑ Distance to nearest lot line------ ------------------------------------------------------------------------------------- Remodeling and/or repairing {describe): `------------• ----- ------------------=- ---------------- __-------------------------------------------------------------._------_--_-_-__-_----__-_.---_-____---___----__---_.------_---_____------______-----__-__--.-_---__-__--_-_------_-_-•---__-F-_--___._-..---_-__--._--_.._ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St to laws, and ru s and regulations of the San Joaquin Local Health District. (Signed) . a C/.(% (Owner and/or Contractor) / . .By:--------------------------------------------- ------------------------------1.. (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). p FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.....7.-t:1_`- Q---------- ---------------------------------------------------------- DATE------ -3---r-/ REVIEWEDBY-------------------------------•------- --- ----------------- ---------- ---------------------------------------------- DATE----- BUILDINGPERMIT ISSUED-------------- ------------------------------------------ ---•--------------------- - ---------------- DATE Alterations and/or recommendations: ------------------••----------------------------------- -- ------------------------------------ '�i = 1 1#4 - ------------------------------------- ------------------------------------------------------ -------------------------------- + -------------------------------------------------------- ------------ ------------------------ ---------------- --•---------------- - ------------------------------------- --------------------------------------------------- --- FINAL INSPECT - ---- -- Date "ON $Y:- -------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:ellon Aye. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.RCO.