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FOR OFFI �� /��'nis c�i•«SAF rim♦<•�,.4t <br /> APPLICATION FOR SANITATION PEcRVIT _-Permit No. ... .7 <br /> (Complete in Duplicate) P�R (. 2 3 <br />--------------------------------------------------------- / <br /> . This Permit Ex fres ] Year From Date Issued Date Issued ____________ _�-b <br /> Application is hereby made to the 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 549. <br /> . .r <br /> JOB ADDRESS ANDOATlk � <br /> --- ----------------------------------------•--------•----••---• -------------------------- <br /> 1 --- --------------- Phone........------------- <br /> Owner's Name �1------------------------ <br /> Phone----------------------------------- <br /> -------------- <br /> .-•------.._.._-_--•- <br /> ----------•-•-Address.----- ---- ------------ --- <br /> Contractor's Name--------- <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: .___ Number of bedrooms _/___ Number of baths ._t__ Lot size _4PAPOk1"____.......______________________ <br /> Water Supply: Public system E1000c"ornmunity system ❑ Private ❑ Depth To Water Table A: tt.� <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe -lardpan ❑ <br /> Previous Application Made: (if yes,date--------------------1 p�New Construction: Yes ❑ No 2 FHA/VA: Yes ❑ No 99— <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ` <br /> S!Etic.Tan6 Distance from nearest well-----------------Distance from foundation--------------------Material--------------------------------------.......... <br /> � $ No. of compartments--------------------------Size--------------------------------Liquid depth-----. ------------------Capacity----.--••------_.----- <br /> :E <br /> Dis osal Fief: Distance from nearest'well_______________Distance from foundation.._sl� ._...Distance to nearest lot line..a I��..... <br /> Number of lines.......... f__. ___-__ _Length of each line '41140 Width of trench._ ----------------------- <br /> Type <br /> of filter materialDe Depth of filter material._ ._ ! Total length---- <br /> to <br /> en th____.-- <br /> 77 P g ' ----------------------- <br /> -------------- <br /> / <br /> Seepage Pit: Distance to nearest ell-----'�'_________Distance fr m fo 145P to nearest lot line____.._ <br /> Number of pits-- ----------------Lining material_ -Size: Diameter'.._-..____...Depth_ ....__ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---.----------------Lining material___-____-_--________._._..__.._...--- <br /> ❑ Sizer Diameter------ -----------------------------•_Depth--------------------- ----------------------------_Liquid Capacity-----------------------....gals. <br /> Privy: Distance from nearest well------------------------------------_------------Distance from nearest building----------------------------------------. ` <br /> ❑ Distance to nearest lot line.------ ------------------�•-----------------•--------------•------------•----.-------------------------------------- <br /> Remodeling and/or repairing describe):______-_---• 4% -- ----____-- - 4 <br /> ---------------------•-•--------•--••--••------------------•-•--------•----------------- -----------------------------------------­ ------•-•--------•---------------=•-----------------•-•-----••----------------------- <br /> ------------- <br /> ----•-•----•-------------•----------------------... _.--..----------------------••-•-•-----------••-------------•-------------•----------•---------------- <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, and rul s and regulatio s of the San Joaquin local Health District. <br /> (Signed) ---------------------------------------- lVor Contractor) <br /> By: (rtle} - <br /> (Piot plan, showing size of lot, location of system in ation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__- DATE____` ^__ w$------------------ <br /> REVIEWEDBY---------------------------- -------- - ---------------------------- --------------------------------------- DATE <br /> BUILDING PERMIT ISSUED-------------------------------------------------------------------------------- ------ DATE ------ -------------- <br /> Alterations and/or,ere ommend'afions:-_Z -�-L ------------- •--•----.._..---•----------- �-- - . <br /> ---------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------- ------ ------•-------------------------------------------------•--- ------------------------------------------------------- <br /> FINAL INSPECTION BY:...... .' --- ---------- •---------------- Date-- / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED B-59 2M 5-62 ATLAS <br />