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APPLICATION FOR SANITATION PERMIT Permit No. ................. <br /> (Complete in Duplicate) <br /> Date Issued I'1 S <br /> c 0 C) <br /> Applica+ion is�iire y made to &eS`anAJ"o`afq:�ku_in Epolal Health District for a permit to construct and install the work herein describ6d. <br /> This application is made in compliany with ouOy Ordin nce No. 549. <br /> JOB ADDRESS D LOCAT I!�+e:1AP-7)J------- _X, /7 <br /> ------------- ----------- ----------------- <br /> Owner's Na.. Phon ----- ----- --------------- <br /> ------ -- - -- -- -- ------ -- --------------------------- ----------------------- -------- <br /> Address-----r!- <br /> ---- --- ------------- ------------------------ ----••-----I----------------....... <br /> Contractor's Name------- ---- -- ------------ ----------------------------------------------------------------------------------------------------------- Phone--------- ---------------- <br /> Installation will serve: Residence Apartment House [] Commercial F] Trailer Court E] Motel E] Other E] <br /> Number of living units: J/,�umber of bedrooms -24-- Number of baths .1--jot size --------------------------- <br /> r Water Supply: Public system M Community system [I .Private [I Depth to Water Table __--_ ft. <br /> El <br /> Character of soil to a 'depth of 3 feet: Sand 0 Gravel Sandy L Clay Loam ClE]ay Adobe E] Hardpan E] <br /> Previous Application Made. Yes ❑ No 91 New Construction: Yeso;pNo El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if publip sewet, is available within 200 feet.) <br /> ------------- <br /> f foundation ____nd a ti o n <br /> ank: Distance from nearesi well �;a n <br /> Sept is a rial---(� <br /> No. of compartments------------ �W 1'0 Y, Liquid c1ppth--------- --------------Capaci <br /> 0 <br /> 7---- <br /> ----Isiz ---------------- ------------ <br /> Dislance from�nearest welll§70__�►--- ance from found i�n'__10. �I�istance to nearest lot 11 <br /> . ------------- <br /> Disp 0 Field: <br /> Number oi I?he's--- Width of trench <br /> _.- . - �1 --- --------- <br /> In I _J---- -------- length___._______�_,Q_�_________________ <br /> Seepage <br /> ----A,_____,_ L9ng1h of each line. .... .......Total len fh----------- <br /> Type of filter maters 'pt of filter material------- 9 <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------_-----------Distance to nearest lot line____.___________-: <br /> ❑ <br /> ine----------------- <br /> F1Number of pits------------------ ---Lining material---------------*--------Size: Diameter----------------_.-.--.Depth-------_------------------------- <br /> Cesspool: Distance from nearest well----------------Distance from foundation--------------------Lining material------------------------------------- <br /> r_1 Size: Diameter_____I-------------------------------Dept h- ---------------------------------------------------Liquid Capacity.---------------------------gaisl. <br /> Privy: Distance from'nearesf yell------------------- -----------------------------Distance from nearest building---------------------------------------- <br /> ElDistance to nearest lot line-------------------------- ------- ------------------------------------I---------------------------------- --------------------- -------- <br /> Remodeling and/or repairing (describe):--------------------------- ---------------------------------------------------------------------- --------------4•-----• --------------- <br /> ---------------I <br /> --------------------------------------------------------------I----------------------------------------------------------------------------------------------------------------------------------------------- I — <br /> ---------------------------------------------------------------------------------------------------------------------------------r--------------- --------------------------------------------------------------------41� V) <br /> - ------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------!------- <br /> I hereby certify that I havepreparedthis application and that the work will be done in accordance with San-Joaquin Coun), - <br /> ordinances, State laws,: and rules and regulations of the San Joaquin Local Health District. <br /> (Sign ---------------- ------------------------------------------Owner and/or Contractor] <br /> By:----------------------------------------- ------------------------------------------------------------------------------------------(Title)--------- ------------------------------------- ------------ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY!_j <br /> ----------- --------------------------------------------------------------------------- DATE_______________________________________-____.._ <br /> -----�1_�_ --------------------------------------------- <br /> REVIEWED BY_------------------------- - - - ----------------------- - ------------------------------------ DATE �6 <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------:----------- --------------- - DATE----------q��----------------__--------------------- <br /> Alterationsand/or recommendations:----------------------------- ----------- ----------------------•---•------------'-------- ---------------------------•----------------------------------------------------------- --------------- - <br /> --------------------------------- <br /> -------------------------------------------------------------------------- ------------------- ------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------I-------------------------------I--------------- ----------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------- ------------------------------------- ------------------------------------------- ----------------------- ---------------------:----------------------------------------------- <br /> -------------------------------------------------------------�­------- <br /> FINAL INSPECTION BY--- ---------------I----------------------------------------- Date--- - <br /> -{-5�, - <br /> SAN <br /> ate-----SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M I Revised W-2100 <br />