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FOR OFFICE USE: ' , ----------------- ------- ------------------------------- 2 3 APPLICATION FOR SANITATION PERMIT Permit No. ________________ -- ----------------------------------------------------- (Complete in Duplicate) Date Issued --------------------------------------- ----------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance ith County Ordinance No. 549. At Cul o Avs SO _ JOB ADDRESS AND LOCATION/-_51-17E - --1.I C—rL-1-O �Jir��1\F�-------�`11-14�z-1��(�--�� ---/ (��1��--,------ Owner's Name------------ - �� 7----------��-) --�TS--------------- --- --------------- ------- ------- - Phone--------------------------------- Address _T -'A Q x f5 I__F'Ol ----- __ Contractor's Name--- �, Gl�tr/ 1--! _..-- IG=----- ------ Phone----------------------------------- Installation will serve: Residence OrApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _j Number of bedrooms 3- Number of baths _1-_-- Lot size ____t 4_R _17Cr- ----------- - Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 90 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,ET" New Construction: Yes ©—No ❑ FHA/VA: Yes ©1-1 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Q Septicfank: Distance from nearest well_�___�_-----Distance from foundation___I_____________ Material__P1 ' `7 FI-T-F—....--.--. � No. of compartments------Z--------_____Size___.-5........ ___Liquid depth___-5—..`------------Capacity---/J_ ---- Dis osal.Field: Distance from nearest well--- _�Q._....Distance from foundation-----/0--------Distance to nearest lot line---- Number of lines-----------L...-----_-.._Length of each line------ rr_____-Width of french--------- __------------------ Type of filter material__. '!�_C.J __.Depth of filfer material------l. -.--------Total length-----------------/5_-f_--�_ ------------- Seepage Pit: Distance to nearest well__- 5 --------Distance from foundation_-__- --------Distance to nearest lot line----- ❑ Number of pits------/-------------Lining material---f_toe C _Size: Diameter--;?-----------------Depth......��.__ Cesspool: Distance from nearest well-----------------Distance from foundation................... Lining material-....-....-_--._------_-_-------.----. ❑ Size: Diameter------ -------------------------- -- Depth-------------- ------------------- -----------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------Dis#ante from nearest building.___.__----.__-----__------_-_-.._--_._-. ❑ Distance to nearest lot line- --- ---- ------------------- - --------- ---------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------- -----------------------•--------------------------------•--------------------------------------•---------------------------------------------------------------------- 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 a regulatfions of e n Joaquin Local Health District. (Signed)----- - - -- ------ --------------------------------------------------------------------(Owner and/or Contractor) By:----------------------------------------------------------------------------------- ------------------------------------:-------------(Title)----------------------- ---------- ----- ----------------- (Plot - --------------(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ------ � ..0 ------------------------------ ---------------------------------------- DATE--------�� -�/ '- .1 REVIEWEDBY------------------------------------------------------------------------------ ----------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations--------------- ------- ---- ---------- ------------------------------------------------•-----•-••----•----------------------•-------------------------------- ------------ ---------- ------ -----------•----- ------------- ---------- -----------------•---------------------------------------------------------------- ------------------------------------- ------------------------------------------------------------- ------------------------------------ ---------------------------- ---------------------- -------- --- - ---------------------------------------------------------------------------------------- FINAL_ INSPECTION_BY, -- �1 -. 17Z Date-------------er- _20_ k ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ma:elton Ave. 300 West Oak Street 124 Sycamore Street 205 west 9th Street Stockton,California Lodi,California Manteca,California Tracyr California F.P.0 C.