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OR OFFICE USE; . <br /> ----------"Id�------------- <br /> < APPLICATION FOR SANITATION PERMIT Permit No.-/ <br />-------------------------------------------------------- <br />----------- - ------------------------------------------- (Complete in Duplicate) Date Issued <br />---------I-------------I---------I----------------------- This Permit Expires I Year From Date Issued <br /> Application is hereby made to the Sa;'JoaqZiin 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,_IrOCATION......o�� ------------------------------------------------ -----------_---------......... <br /> Owner's Name_. -------------------------------------- Phone.................................... <br /> Address --------------- ............................................­.......................... <br /> ------------- - X,----/ ..... <br /> Contractor's Name----------------- =7- ---------------------------------------------------------------------------- Phone........ --_--------------- <br /> Installation will serve: Residence M'Aparfment House [] Commercial L] Trailer Court [I Motel [I Other El <br /> Number of living units: ./__ Number of bedrooms A-- Number of baths Lot size ------.._ <br /> Water Supply: Public system 9rCommunity system El Private B'Depth To Water Table XPft <br /> Character of soil to a depth of 3 feet: Sand E] Gravel El Sandy Loam Ll Clay Loam C] Clay C] Adobe e--Hardpan [1 <br /> Previous Application Made: (If yes,date____________________} No IZ4,- *New Construction: Yes [] No 0--' FHA/VA. Yes 0 No 9— <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No Septic tank or cesspool permitted if public`sewer is available within 200 feet.) J. <br /> Septic Tpilk Distance from nearest ____..Distance from foundation_____/4�...... .............. <br /> ,EAAY1sqP11No. of compartments.....:2—----------------Size-,,Y(-_ ,O'`_....Liquid depth-----js.��..............capacity.1009a--------- <br /> I * IF <br /> _______-Distance to nearest lot line._4........ <br /> Disposal Tieglcl- Distance from neares well..-?a------Distance from foundafion-.AJO <br /> ----- ----------- <br /> ;;S ---- Length of <br /> Number of Lines---- - each line-----al*1-----------------Width of french. -------- <br /> Type of filter material/./X40�eDepth of filter material____ ____-Total length.....�Z7------------------------- <br /> Seepage Pit: Distance to nearest well___,If0/--Distance f u <br /> fro fou Distance to nearest lot line--.;%7./-- <br /> Number of pits------�------------Lining Size: Diameter. Depth_.Xt,1-i"7_'_____.......... <br /> Cesspool: Distance from nearest well-________________Distance from foundation--------------------Lining material------------------------------------- <br /> El Size: Diameter---------------------------------------Depth----------------------------------------------------Liquid Capacity----------•--•-----..-------gals. <br /> Privy- Distance from nearest well-------------------------------------------------Distance from nearest building______-__.______.________________-____-. (/� <br /> ❑ Distance <br /> uilding----------------------------------------- <br /> Distanceto nearest lot line---------------------------------------------- ----- _------------------------ .........r.--------------------------------------- <br /> Remodeling and/or repairing (describe):--------- �-- <br /> - ----- - <br /> ; 00---------- gpp ---- <br /> ....................... ----------------- ----- <br /> ---- -------------------------------------; 7- <br /> ----------------------------------------------------------------4 ----------- <br /> ---------------- <br /> ----------------- - --------- --- ------------------------------------------------------------------------------------I.............. <br /> -------------------------------------------------------.__.....---------•-•------------------- -----------------------------------------------------------------11---------------------------------------------------------- <br /> I 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, gpd rules and regulations of the San 'Joaquin Local Health District. <br /> Contractor) <br /> {Signed)............. ---------------- -------- Z_ - -------------------------------- <br /> -- ------- ... ......o0j;X>-----------(Title)----- ------------- ------------ <br /> By:------------------------.........................__-------------------- L`� <br /> (Pic+ plan, showing size of lot, location of system i*ion to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> 0(/ <br /> APPLICATION ACCEPTED BY------- DATE---- ---------------- <br /> ------------------------------I----------------------------- <br /> REVIEWED BY--------------------------------------------- DATE <br /> - -------- <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------- ------------------ DATE------------------------------------------------------------- <br /> Alterations and/or reccVnmer)dations:--------------- ---- -------------- ---- ------- ---------; -- - ------------------- <br /> ----------- ----------------------------*------- <br /> pt. r•-------------- <br /> FINAL <br /> 1------------ <br /> FINAL INSPECTION BY:------On----- - Date------- -------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Sirtat 124 Sycamore Street 205 West 911%Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 4 REVISED 8-59 2M 5-62 ATLAS <br />