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-------------------------------------------------------- <br /> - -------------------- <br /> ----------------- ------------- APPLICATION FOR- SANITATION PERMIT Permit No. <br /> --------------- 4/ <br /> (Complete in Duplicate) <br /> -------------------- ------------------------------------- <br /> -- - ------------------------ <br /> This Permit Ex fres 1 Year From Date Issued Data Issued <br /> Application is hereby made tcthe San 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 /> JOB ADDRESS AND�O ATION-L?OL .1. <br /> --------------- ---- .....--------------•------------•-••-------••----- <br /> Owner's Name----- --- . ... . <br /> C&-------- ----------------------------- -------- ------------------------------------- <br /> Phone- <br /> Address------/ - <br /> 2 . -------------- <br /> ................ --- -------------- --- --- -- ------- <br /> Contractor's Name_________________. --- ------.......................................-------i........................................ <br /> ------------------------•-------••--------••---------•-----------------------------------------.... Phone <br /> Installation will serve: Residence, A rtment House [] Commercial El Trailer Court Ej Motel ❑ Other 0 <br /> Number of living units: Nu"Mber of bedrooms-3-.. Number of baths' <br /> I' _J--- Lot size <br /> Water Supply. Public system El Community system C] pri` <br /> vate El Depth to Z�terTabl, <br /> Character of sail fo a depth of 3'fe6t:' Sand El Gravel Ej "Sandy Loom ❑[f] "Clay Loam ❑r Clay <br /> El 'Adobe Hardpan <br /> Previous Application Made: (If yes,date--------------------) N New Constlr*6ction: Yes ]Nl4o �HA/VA: Yes C3 N <br /> Ik No <br /> TVpt OF INSTALLATION AND'SPEI <br /> tic� a9k or. ,SPECIFICATIONS: 14 1 1 <br /> mSSRO?l permiffed,if pu6li"e�wer <br /> (No sep� _t __is,avaiIa6Ie,w1fhin_200 feet.) <br /> _j <br /> 1�0*AT 10 N <br /> .......... <br /> '4----------------------- <br /> _.._ <br /> I <br /> Ice; <br /> Se pt;T Ta <br /> ptiT Distance from nearest well______________ Distance from foundation f.material <br /> No. of compartments------------ Size..._ ------------_-----t - <br /> i Ppoial Field: - r _Liquid clep�h------­----------------Capacity----- <br /> ce from-foundation__A-04 Distance to n"earest lot fine__ <br /> Number <br /> Field: rn nearest -D Distance tan ---- .......... <br /> i P Distance fro ,�st ell---- I ....�s <br /> r -- ----- <br /> Number of lines__________ - ------------ trench.___,., <br /> ... ...... <br /> lj <br /> .:T!.­.Length of <br /> --------- ---- each line------1421 57 Width of trench. <br /> , - ��of filter materia <br /> Depth of filter materia ---A--------------Total length--.--,P. ........................ <br /> Seepage Pit: Distance to "nearest well-------'-_----------Distance from found- ation--------------------Distance to nearest lot line.......... <br /> El Number of pits..__---_.--------------Lining material---------- ------------Size: Diameter------ ------- <br /> I �4 4 ------I........Depth.......................... <br /> Cesspool: Distance from nearest well-----------------Distance from foundation______________ ....... <br /> Size: Diameter----- -----------Lining material-,........ ......_................ <br /> ❑ ----------Depth---------------_----------- -.#- <br /> Priwy-:_ .E -Di_ ------- ------------Liquid Capacity--------- .-gals. <br /> Distance from neare'st�we`ll ` ­--------------- <br /> --------- -------­----------­ <br /> ----------------------11------------ -------- ------------------------------------------------------------- <br /> 0 Distance to nearest-lot line_---------------------------------------------------Distance nearest�uilcling= <br /> ------------------------ f - <br /> F <br /> Remodeling and/or repajr*W (describe): ------4_,d, <br /> ---------- . .... --------- ......... <br /> -------- ---------- <br /> _( M-P - ------------------------------- <br /> -------------------- <br /> ---------- <br /> ----- --------------------- ........ ------------ --- <br /> ---------- _V-------- <br /> -------- - ------ ------------------------------------ <br /> -----:2�_ ---------------------------------- ----------------------------- 0------------**--- <br /> Ihe ----------------------------------------I----------------------------------I-------I---------- <br /> reby certify that I have prepared this application and that the-work will be done in accordance with San Joaquin County <br /> ordinances, state laws( nd rules and regulations of the San Joaquin Lccal'HWth,District. <br /> (Signed)_,--XAt_�. ...... 1� f '­ I <br /> -------------------------------------- <br /> -----------------------W�-----------------(O wner and/or Contractor) <br /> jy:---------------------------------------7........ I <br /> -------------------------%--------------_-----------------(Title)-----;-------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverseside). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY_-__ _.____-I_---------------- ---------------------------------------------------------------- DATE---- <br /> REVIEWED BY............ <br /> ---------------------- ------......................... <br /> ---------- <br /> BUILDING PERMIT ISSUED----.- I-----------------------^r----------------------------- ------------------ DATE--- <br /> - I-V--- ----------------- <br /> Alterations and/or recommendations____ ______________----------------------------------- -------- -- -- ------------ ............ DATE------ <br /> ons.__J --------- ----------------o4�------- <br /> A ----- .. ---- - ---- -----------_---------- <br /> -----------------------------------------------------........ . ...............................................I--------------------- ------- <br /> ----------- --------- ----------- --------------------------------I....................­......................---------------...................... <br /> ----------------------I----------- -------------------I--------- ­-------------------------- -------------------------------------------------­--------------------I------------ --------------_------- ---------- <br /> .......................................................... -------- ------------------ ............----------------------------------------------------------------- I <br /> .................................... ­........ ..... --- ------------ --------*-------------------------- <br /> - -------------------------------------------------------------- ----------------------------------------------------------- <br /> FINAL INSPECTION BY:__._...--- <br /> Date---- ----SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street '�300 West Oak Street <br /> Stockton,California 124 Sycamore Street 205 West 9th Street <br /> Lodi,California Manteca,California Tracy,California <br /> ir 4 REVISED B.59 2M 3-151 ATLAS <br />