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Vi <br /> /,,1-,3 <br /> APPLICATION FOR SANITATION PERMIT Permit No. ./ <br />----------- ------------ ---------- --------- (Complete in Duplicate) Date Issued <br /> ----------------------------------- This Permit Expires I Year From Date Issued <br /> Appliciition is hereby made to the Sai Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> il <br /> & q <br /> . k _(.11 --------------,•................ <br /> LOCATION ........�n­,�4 ----------------- <br /> JOB ADDRESS AND <br /> ------ ----------- <br /> Owner's Name------- 11S. &.1-17m. . .... - --------- -------- ------------------- Phone................................... <br /> --------------- -------------- ------------- <br /> - - <br /> Address--_-------------------- <br /> Phone. <br /> ------------ <br /> ---------- <br /> - - -- ------- <br /> Contractor's Name...... ..... . .. <br /> A per Motel 0 Other E] <br /> �04. X <br /> Installaflon will serve: Residence House [I Commercial E] Trailer' Court (3 <br /> Number of living units:�a_ umber of bedrooms .......... <br /> N Number baths,�. Lot size.../ - 70.......... <br /> Water Supply. Public system [D/Clommuriity system El Private E] Depth to Water Table u ft. <br /> Character of Wil to a depth of 3 feet: Sand [] Gravel 0 Sa Loam ❑ Clay Loam [3 Clay E] Adobe[0-'—Hardpan <br /> ❑ <br /> Previous Application Made: (if yes,diote-------- ------ No M��Ne, []Construction; Yes [j No [37FHA/VA- Yes E] No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool.IP�irmifted if public sewer is available within 200 feet.) <br /> Septic Tan Distance from nearest well-----------------Distance from fou.nclation--------------------Material................................................. <br /> No. of compartments--------------------------Size.......--------------_------_ Liquid clepth--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line_...._.._._._.... <br /> Number of lines_'�---------------------------------Length of each line-.------------------_-------Width of trench-------_------------- ---­------- <br /> Type of filter rnaterial-------------------------Depth of filter ma6ial...--------------------Total length__________________________________________ <br /> Seepage Distance to nearest well----------------------Distance from foundation .............Distance to nearest lot line. <br /> �/P Number of pits-JI...1--------------Lining material--- !--Size: Diameter...... T..........Dept h..... f. <br /> I - ----- --------------- <br /> Cesspool: Distance from nearest well------------....Distance from f6undzi4ion------------------_Lining material____........______..________.__..-.-- <br /> IJ Size: Diameter_--Distance from <br /> :-----------------------------------Depth----------------•------- ----------------- - -------------Liquid Capacity----------------------------gals. <br /> Privy: nearest well_..._-___---------------______---------------Aistance from nearest building_---_---_----_--__--_-__-.._____._---.-. <br /> ❑ <br /> uilding--------------------_---- ------------- <br /> 0 Distance to nearest lot line--------------------------------------K1 --------------------------------------------------------....... ------------------- --------- <br /> Remodeling and/or repairing (describe)--------------t' ------------------------------------------------------------------------------- <br /> -------------------------------------------- ------------------------ ---------------------------------------------- <br /> ............... <br /> --•---•------•-•------•----..... ------- ---- - <br /> I ---------- <br /> ------------------------------- -----------------....... ------------------•------_._--------------------------------------­------------------------------------------------------------- <br /> ---------------------------------------------- --------------------------------------------------------------------------------------------------------------------- <br /> --------- -e-re_b---y-,--c--e--r-t-if--y-,--fha+-.I-hay-e-prc,pared this ap.plicatio.riand that the work-will-be done in accordance with San Joaquin County <br /> ordinainces, State and rules and regulations of +han Joaquin Local Health District. <br /> 2q <br /> (Signed - �,o -D.-U---�_ _.- --------- --------------(Owner and/or Contractor) <br /> ---------------- - ----- --------- -- -----------7------------------------ <br /> 'fie)----- <br /> -- -----------(r <br /> o o-ca'tio' of system in relation i wells, buil' ------------- <br /> By:------------------ ---------J_N, <br /> I wells, builk, irigs. etc., can be placed on reverse side). <br /> ,(Plot plan. showing six 3f-o <br /> 0 <br /> FO DEPA TMENT USE ONLY <br /> a. <br /> APPLICATIONACCEPTED B ------------ --- ----------------------- -------------------------------------------- DATE-----------. --------------- --- ------------------------ <br /> REVIEWED BY-----------------• •*'*'*------- --------• <br /> ----------------------------- .--••-----------•----------•••-•----------- DATE--------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED_---------- ...........------------ ----•--------------------------------------------. ---------- DATE.------ -------------------------• -------------_--------- <br /> Alterationsand/or recommendations:-----------------------------------------_..................---------------- ......................----------------------------------------------- <br /> ------- ----------------- -- -- ---------------------------------------------I..........................................................I............................... <br /> Ac-------------------------------------------------------------- ------------7....... -- ------- <br /> ------- ----------I ------ ----- ---­--- -- ------- ------I---------------------------------------------------------------------------------------------------------------------- <br /> _­....... ----------------_ <br /> --------------- -------------------------- ------------------ ------------------------- --------- -------- -------­---------- ------------------------------------------------------------------- ---------------------- <br /> FINAL INSPECTION BY:..:---..--. <br /> Date---- ...L_ .C_.:7r0-------—----------------------- <br /> SAN JOAQUIN LOC <br /> -- <br /> AL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California i Lodi,California Manteca,California Tracy,California <br /> EB 9 REVISED 8-59 2M 5-61 ATLAS <br />