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APPLICATION FOR SANITATION PERMIT ' ` � Permit NOS7 „(,Complete in Duplicate) �i Date_Issuelv ed - '`- Applica�ion is hereby made to the S/Joa L cad"I Healfih Disfiric+for a permit to construct and installthe work herein described. Thisapplication is made in complianunty Ordinance No. 549.JOB ADDRESS :_._" ------•----------------•------------------------------•---------- jq wner's Name '-------------------------!-- �- Ic nj--- -- 11� Phon °_. ✓ Address---------------------------------' .. - --------------•--------------------------------- -------------------------------------• --- Contractor's Name-•--------•--•----------•---------- --- ----•----------------••-------•- _ .+ •----------��-j-------t-="- -- I -- • ---- Phone nstallation will serve: Residence Apartment House ❑ .Commercial ❑ Trailer Court ❑ Motel Oth Number of living units: -"_ Number of bedrooms Number of baths -------- cf�ei ❑ Lot size ------ Wafer, Supply: Public.system>0 Communitysystem Y.stem ❑ •Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay --Previous Application Made: Yes No ❑ Y ❑ Adobe Hardpan ❑ ❑ New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPE *1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well." _ foundation ! V Size-""__ °m __._" Material---.--- _ No, of compartments------_-_"-- _-- _ -------------•__-• Y ------Liquid depth s !C-----Capacity----."� 4?-- oil) Disposal Field: Distance from nearest well - _-_Distance�rom foundation_"-_ " " Distance to nearest lot line--_--- -/ W; Number of lines_"""_"""_""" _ �"--" " --- _ ~-i - Length of each line_ Type of filter material_"--"- � � " 0----Width of trench." _""-_ ±,�!�_-" }--------_---Depth of filter material------/Vhf---------Total length_" ------ Seepage Pit; Distance to nearest well_-"" Distanr.,Q'loon a i n"""____"� r � ❑ Number of pits------ ..... --------Distance to nearest lot line----- __"_ ---------Lining material '` Siz Diameter- �- ------ Depth--------- 2rCesspool: Distance from nearest well ___- � -- -_Distanounciation-------___-____---.Lining material--------______"- •` ❑� Size: Diameter-------------- ---------------- -.Depth- -- _ -•--------'� �.r -------= ----• -----------------------------Liquid Capacity--------------- -------- Privy; Distance from nearest well Distance from nearest building__" ""____-____ . ❑ Distance to nearest lot line = I ------------------------------------------= -----------------------'---- Remodeling and/or repairing (describe):_--_--_-:_____" -------------- --------- "."" """."" "_" i -------------------------- - ._-""._"-".-""."__""."__-"""""""""".._`------.--------------------..__--_____"______----------------- --------_-------------------------- ___________'--_---_--------!:___ - ---------------- L Ar ------ ""«""""-"""""""-_-"""-"""""_."""_-___"""""_.______"_.,----------------.---------------------------------------------------------------------------------------------------------------------------------------------- -. `- I herebyrcerflfy that I have prepared-this applicefion and that the work will be•done in'accordance with San Joaquin Count ordinances, State laws, and rules and r ulafions of the San Joaquin Local Health District, y (Sign•ed)-------- , - f ----t- ------A-- . _ .. . '. ' - ------------(-T--i-t--l-e-)-'-------`--------- r and/or Contractor)By:----*------- - ------------------•------------------ ------- (Plot plan, showing size of lot, location of system in relaafion to wells, buildings, etc., can be placed onreverse side). f �. FOR DEPARTMENT USE ONLY ti 4- - APPLICATION ACCEPTED BY------- --- - REVIEWED BY-------- U� DATE ; - BUILDING PERMIT ISSUED_•----=---------=----•- - -- --------------•---------------------- DATE -•------ - .�--- --" `-------------------------------------------- ------- ----------------•------ AI era 'ons and/or race mendations:------- = - R ATE" __ 03�oi rl :_sa f ------------ ------- - - �c``e�_ Q� •-- ----------------------------------------------- ---------- &........ ---------- ---------V--- FINAL INSPECTION BY: ".-.--__ �� 6 Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street I 132 Sycamore Street ,r.•� 814 North "C" Street Stockton, California Lodi, California 4 Manteca, California Tracy, California f ES-9-2M Revised W-21o•Q !+