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APPLICATION FOR SANITATION PERMIT Permit No. ------- <br /> (Complete in Duplicate) Date Issued <br /> 17 06�O -2-77 <br /> Application is hereby made to the n, oaqui a It f construct and install the wo4 herein described. <br /> I t District or a permjt!� <br /> ith Countya� <br /> This application is made in complia r7inadce No. <br /> 549 <br /> A-It <br /> --------- - --------- ---------- <br /> AND__LOCAT11ON_ ------- <br /> JOB ADDRESS d <br /> Owner's Name- ---- ------ - - --------- Phone----- = Q- <br /> -----------Address---------------------- -------- 077-4;L_dy -------1-s-, ?_i�---------- ----------------------------- <br /> ---------------- Phone--- <br /> ---------------------------- <br /> Confr6ctor s Name------------ ----- -- - ----- <br /> Installation will serve: Residence00PApar+men+ House [I Commercial 0 Trailer Court E] Motel 0 Other <br /> Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size --- ------------ <br /> /—ZA <br /> Wafer Supply: Public system Community system El Private R Depth to Water Table ft. <br /> Character of soil to a depth'of 3 feet: Sa cl [I Gravel E] Sandy Loam E] Cla fLoarn El Clay ❑ Adobe 2L Hardpan El <br /> Previous Application Made. Yes E] No New Construction: YesEl No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ' <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> fic—Lan Distance from nearest well-----------------Distance from foundation--------------------Materjai---- ------------------------------------------- <br /> No. of compartments---------- --- ----------Size--------------------------------Liquid depth-------------- -----------Capacity--------------------- <br /> j <br /> t. 1 ;5a) Fj�ijd: Distance from nearest well-----------------Distance from foundation------------------- Distance to nearest lot line.----_-_____ <br /> Number <br /> ine------------ <br /> Number of lines-----------------------------------Length of each line-----------------------------.Width of trench.-----.---------------------------- <br /> Type of filter material-------------------------Depth of filter material __-_.._____.Total length________...___-_______.______________._._ <br /> .. ......i13 <br /> Se e Pit: Distance to nearest elk�rP_41 e-+---Distance fr9w foundationPLS..."01 Distance to nearest lot line------ <br /> 9 Number of pits----1��-----------Lin-i-ng maferiald4_4"_ ____Size: Diamefer____A/T_//.___.Depth-.9---Ir--.11------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Uning material___.____.._.___.____.______.__.___.__ <br /> ❑ Size: <br /> aterial------------------------------------- <br /> Size: Diameter------------------ -------------------Depth--------------------- ------------------------ ....Liquid Capacity----------------------------gal <br /> Privy: Distance from nearest well---------- -------------- ------------ ----------Distance from nearest building.______._____.-.- -.-----____..__.____. . <br /> ❑ <br /> uilding------------- -- -------------------- <br /> ElDistance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):------------------- ------------------------------------------------------------------------------------ ----------------------------------------------- <br /> ----------------------­------------------------------------------------------------------------------------------------------- ---------------------------------------- --------------------------------------------- - <br /> ----------------------------------------------------------------------------­-------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------- ---------------------- ------------------------------------------------------------------------------------------------------------- <br /> ----- - ----- <br /> ---------I__her-e --cerf-i-fy-th-a-f-i-ha------prepared i, a pli tion and A t the work will be,dione in accordance with San Joaquin County <br /> L <br /> ordinances, State es qnd rpulations f he San Joa uin Local He A District. <br /> L <br /> ........ . ... ...L <br /> ------------------ ---------- ---1--jo----- ------- --------------------- - ------Pmnep-anWawr Contractor) <br /> (Signed)------------- -- ---- ---- ---- `7 -/= i <br /> By:------------_-------------------------------------- <br /> ------ ----------- -------- --- - - - -- -------- ---------------- ...... <br /> (Plot plan, showing size of lot, location of system in relation tow is, buildings, e can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------------------------------ /--- ------------------------------------------ DATE-------------- --------- <br /> ,5 <br /> / As <br /> REVIEWEDBY--------------------------------------------- -----------------------Z---------------- -------------------------------------- DATE------------------------------------------ ---------------- <br /> BUILDING <br /> ATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE---__------------------------------------------------------ <br /> Alterationsand/or recommendations:----------- -------------------------------------------------------------------------------------------------------------------- ------------------------------ <br /> -----------------------`----••----------------------•------- -------------------------------- ----------------------------------------------------------------------------------------------------------------------------I--- <br /> -------------­------------------------------------------------------­- ----------------------------------------------------------------------------------------------------------- --------- --------------------------- <br /> ---------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------- ------------------------------------------------ ------------ ------------- ------ --------------------------------­------ ------------------ <br /> Date_.. -------6 ------------------------------ <br /> FINAL INSPECTION BY.-,---�_4----- -- ....... . ------ -- - ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Streof 300 West Oak Street 132 Sycamore Street 814 North "C" Sfrevf <br /> Stockton, California Lod;,'California Manteca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 <br />