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Permit No. - -7-E APPLICATION FOR SANITATION PERMIT \� (Complete in Duplicate) Date Issued .--3/ 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 with County Ordinance No. 549. p �f JOBADDRESS AND LOCATION-------------�;-Cafe- -------- ----- --------------------------------------------------------- ------------------ ---------- Owner's Name---'2 :. Phone" - �r" ------------------- ----------------- Address-,.,. --------------------------------------- -------------------_- -------------------4------ -------- it_fn_�-----X€ �' Phone_L�� ''Y - Contractor's Name___________ - -- Installation will serve: Residence [& Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _--._-__ Number of bedrooms ^-7_._ Number of baths ---I--- Lot size ___ ----------------------------------- Water Supply: Public system Q Community system ❑ Private ❑ Depth to Water Table,? t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[a Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation------------.-------Material------------------------------------------------- No. ______---____.________--____________-_-____.No. of compartments--------------------------Size-------------------------------Liquid depth--------------------------Capacity------------------.---- Disposal Field: Distance from nearest well /NWi� Distance from foundation___— --------.Distance to nearest lot line__ Number of lines-------_------_ -------------------Length of each -------------Width of trench---_�f_'__---__________--____ Type of filter material ar4-------------Depth of filter material__/___-_---______Tota4 lengfih_____, __-_____________---_J___.____ .S 14 $eiy' �t: Distance to nearest well----P44 t------Distance from foundation-1-0-'r------------ to nearest lot line___"__._________ p -------- ------Lining material--- Rd-� Size: Diameter------J'k<A ------ D,pth-----7------------------------ Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material___________-____-_______----________. Number o its p -Li Liquid Capacity als. ❑ Size: Diameter--------------------------------------. Depth----- -------------- ----------- ----------- q p Y- ------------- -------- 9 Privy: Distance from nearest well___________________ __________------Distance 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 and regulations of the San Joaquin Local Health District. Si ned --------- (Signed) --------------------------------------------------------------(Owner and/or Contractor( �J ( 9 )------------` -------tom By:_----------------------- ---- -e(---- --------- ---- --- --------- ------------------ Tale(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------------------------------ DATE---------____--------- ----- DATE_-------— --{-- REVIEWED BY-------------=----------------- ----� ----� ---- -- - ------ --- - �-- - -�- -- BUILDING PERMIT ISSUED------------------------------------------------- ---- - - ----- -- DATE------- ----------------------------------------------------- Alterations an¢.[or recommendatio ____ ---- �y� rte 1�•---�-- - -!-----f------•------ ------- ------------------------------------------------------------------------------------------ --------- -------------------------------------------------------------------------- ------------------------------------- FINAL INSPECTION BY: ----- `---- Date �� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M , Revised 1.57 F"P.CO.