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FOR OFF 7U . <br /> 1st---- <br /> 3 APPLICATION FOR SANITATION PERMIT Permit No. .................... <br /> --------- ------------------------- <br /> (Complete in Duplicate) Date issued- <br /> ssued _111143---------------------- <br /> This Permit Ex fres 1 Year From Date Issued <br /> --- ------ --- <br /> Application is hereby made to-the San Joaquin Local Healfh District for a permit to construct and install the work herein described. 4 <br /> This application is made in compliance with Cq ty Ordinance No. 549. <br /> -.� <br /> G < --------Xe <br /> ..-_ <br /> JOB ADDRESS AND LOCATION__ ------ <br /> ___---------- <br /> _------ <br /> Owner's, <br /> _______ :bj <br /> Owners,Name.---=- -T---------------•------------••----------•--------------------------------------------------------- -------------------•----- <br /> Address �'�- ---- ---•------.._.. <br /> ..._. _ <br /> 3 '7S Phone <br /> Contractor's Name--------- -- --••----------....--- • -----•---------------•----- <br /> Ins}allation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _.__/._ Number of bedrooms _-t_ Number of baths -L_ Lot size <br /> Wafer Supply: Public system [community system ❑ Private ❑ Depth To Water Tableir-P. ft. <br /> Character of soil to a depth of3 feet: Sand E] Gravel ElSandy Loam ❑ Clay Loam [_1Clay C] Adobe Hardpan C]Previous Application Made: {If yes,date--------------------) No New Construction: Yes gNo ❑ FHA/VA: Yes ❑ Noe' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> .(No septic tank or cesspool permitted if public sewer is available within 200 feet) -� <br /> Septic Tank: r Distance from nearest well__ _`__'-------Distance from foundation.�0______________Material.___1 ----••-----------••-------- <br /> No. of compartments.---�-----------------Size_-_-a x_`�-x�-----•---Liquid depth----'�------------------Ccipacity--?"0a13�-- <br /> r <br /> Disposal Field: Distance from nearest well...- Distance from foundation.__/�?--------••--Distance to nearest lot,line. ~......... <br /> 91 <br /> Number of lines----t--------------- ------------Length of each line------ °- ,------------Width of trench._v _..___....---.----------•• <br /> I V <br /> Type of filter mate rial..�_a_�'�--------Depth of filter materiaL_�_�._:____--------Total length___Qfa_..----_--••••----••---•�••-•••- +.,I <br /> Seepage Pit: Distance to nearest well--— from foundation__/b__�-_...__..Distance to nearest lot line_____.___.._._ <br /> ❑� Number of pits-----?----------------Lining material_ a c'E---.---Size: Diameter_._ ___._______ Depth---- --------- <br /> „_--••- -- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------ <br /> ❑ --------------------- ------------Distance from nearest building------------------------------------------ <br /> Size: Diameter-------------------------------------Depth_-.-------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well------------- <br /> l - " <br /> ❑ Distance to nearest lot line.---------------------- -------------------------------------._----•-------- <br /> -----•----------------------------- <br /> Remodeling and/or repairing (doscribe):------------------------- <br /> ----------•-------------•-•-----•---••-------------•-----••-------•-------------------- <br /> -------------- <br /> -- <br /> l --- ----- •---------• --------------------------------•-------------------•--------------------------------------------------------------- ._._.... <br /> ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> •----.____-_-(Owner and/or Contractor) <br /> (Signed) ---- -- - ---- ----------------- <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 DEPARTMENT USE ONLY / f <br /> APPLICATION ACCEPTED BY-------- -- <br /> DATE-- k--- •----- ._.._"_5� ..__.. <br /> REVIEWED BY----------------------- ----------- ------ -------------------------------------------------------------------------------- <br /> DATE------------------------------------------------------------ <br /> BUILDING PERMIT ISSUED------•------------------------------------------------•-----------••- ----- <br /> DATE--------------•------------------------••--------_---------- <br /> Alterations and/or recommendations:--------------------- -----•----- •----•------•--" <br /> ­­ <br /> ----------------------------------------------------------_------------------------- t <br /> ---------------•------------- --------------------------------•--- ------ <br /> FINAL INSPECTION BY:- �_ _____ �/] - --- ----- <br /> - <br /> Date. ---- -------------------------------------- <br /> SA JOAQUI LOCAL HEALTH DISTRICT <br /> l 130 South American Street 300 West Oak STreet 144 Sycamore Street 205 WestIh Street <br /> Stockton,california lodir California Manteca,California Tracy,California <br /> ES 9 REVISED a-59 2M 5-62 ATLAS <br />