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FOR OFFICE USE: <br /> G- ---------------- -----/ ----- <br />------------------------------------- - <br /> _----_-----_-. APPLICATION FOR SANITATION PERMIT Permit No. ...'._/--�' - r' <br /> ----------------------------------------------------- <br /> (Complete in Duplicate) <br /> Z <br /> - This Permit Expires 1 Year From Date Issued k Date Issued .....__ .._ .. / <br /> Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. <br /> This applicatiori is made in compliance with County Ordinance No. 549. <br /> .y <br /> JOB ADDRESS AND LOCATION---v2 _/_`� �_..... ---• =----------- ------ ....._.. ------------------------------------------ <br /> ----- <br /> --------•-------------------------_------ <br /> --"� - - -�--...a- <br /> Owner's Name... Phone <br /> AddressS ----- . ....... .............. .... .... ---------------------------=-----.....•-•-----.-.-_..--�-----------------------------•------- <br /> Contract�'s Name------ t --------------------------------------------•--------. ----•-----. .............._.. <br /> F <br /> �''}` _ Phone. ...-- <br /> Installation will sery R'hsidence X Apartment Hou ❑ Commercial ❑ Trailer Court ❑ Motel [3 Other ❑ <br /> Nu ber of living units: ....-. Number bbedrooms .%'S. Number of baths.-A_ Lot size........1,Y—P .-A.__1--2-.:.............. <br /> Water Supply: Public system-;K ComrnunitySsystem ❑ Rriva'te❑❑ Depth To WINer Table/O. ft. <br /> Charactelof soil to a depthNo�f 3 feet: Sand ® Gravel ❑ Sandy Loam ❑ Clay Liam ❑ Clay ❑ Abl obe❑ Hardpan ❑ <br /> Previous Application Made: (I'fiLyes,date-----------_--------) No S New Construction: Yes F1 No ❑ FHA/VA:'Yes ❑ No OR <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: r, <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Talk: Distance from 'nearest well------—-------Distance from foundation____z U-'__-_.Material.. . ........................................... <br /> 11 <br /> t No. of compartments__.__ _Size_ _ _L _ - .. Liquid de th_A�________________ a aci ��170 <br /> Disposal Field: -,Distance from,nea est well-------__..._Distance from foundation____/_0�'rstance to nearest lot li e._�__---.- <br /> e1 1 (NuM15erE.�of'Ii es___... --- ------------------ ength of each Iin�G '_�_a__,�_.y�idth of trench.- ` .....________.______.__ <br /> Type of filter material Depth of filter�m'aterial__ _�_.._________Total length_.�-_��V_--_____________________ <br /> s . 1 <br /> Seepage Pit: '�Distance to nearest well___________________ ___D.istanc-tee from foundation___.__________.__._.Distance to nearest lot line................. T' <br /> ❑ <br /> Number of pits------------- :Lining material----------.------------5i{z�e:-Diameter------ _-- -Depth----..-....-•-•------------------ <br /> Cesspoal:I Distance from nearest wei!-----------------Distance from fo012ation_____________,�-�7_.Lmmg material.___.______________.................. rJ <br /> ❑ Size: Diameter. I---------------------------•-Depth <br /> ❑ -- -•----------- ;°c ------Liquid Capacity---------------------------- <br /> Privy: _ Distance from nearest well-------- <br /> ------------------rDistance from nearest building------------------------------------------ <br /> iDistance to nearest lot line-----=='�----------- ---------- -- ---------- --------------•----------------•------•-•---•------------------ ------------------------ r <br /> Remodeling and/or repairing (describe}:_ - ----------------------------------------------------------------------------------•--------------------------• t <br /> •----•------..... -•- <br /> .•-----• --------- ..--------•----•--• ------ ---•--------------------------------------------------------------------------------------------------------------- 1 <br /> op <br /> --- = <br /> ---•------•••-- -------'---i-------------------------------•------••----------/-----------------•-•-------------------------------------------------------------------------- --------------- <br /> --------- ----- <br /> I hereby certify that I have prepared this applickon and that the work will be done in accordance with San Joaquin County �1 <br /> ordinance#;'Stlfe I ws- a `d rulei;�d�regulations of,the an Joaquin Local Health District. Y <br /> (Signed)--------fir • � � [Owner and/or Contractor) <br /> By:------------------------------------------------------------------------------- <br /> --------------------------------------•-------•----(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 DEP E T SE NLY <br /> APPLICATION ACCEPTED BY-------- ' ------ ------- ----------------------- DATE----- ('--y-------------------- <br /> -REVIEWED BY. .--_--•--------•------•----•- ---- ----------------- - ------------------------------------------------------ DATE------------------------------- ---------------------------- <br /> BUILDING PERMITA'SSUED---.._.._.......... -•--------------------------- ------------_-------------------------------------- DATE------------------------------------------------------------- <br /> Alterations recommendations:------------------------- <br /> -------•-----------------------------•---- ---.......... <br /> --------------------------------------------------------I­-------­­---- ... .....------- --------�?�-------------------------------------------- ------------------------------------------------ <br /> FINAL INSPECTION BY:---------- Date------- --------7- -6- X----------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American.Sfreet 300 West Oak Street 174 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED B-59 2M 5-62 ATLAS <br />