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FOR OFFICE USE: <br /> ------ -----A L12---- APPLICATION FOR SANITATION PERMIT Permit No. ...... <br /> ---------- ---------------- <br /> ------- ----------------- ----------------------------- (Complete in Duplicate) Date Issued . ................ <br /> -------------------- ---------------- -----------A This Permit Expires I Year From Date Issued <br /> Application is hereby made to the Son 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 ALqCATION....TFo----------------- <br /> ....... ... .... _ <br /> ... <br /> , ------------------------------------------------------------------------------------------------------- <br /> S� ---------------------------- Phone................................. <br /> Owner's Name_A::>&9;_P­—__- <br /> Address............... --------------------------------------------------•---------------•---•---.......---••------•----•--•................. <br /> ....................... ;­------------------------------------ <br /> -- ----------_ <br /> Contractor's Name-- ---------------------------------------------------------------- ---------------------­----.. Phone---......................-------- <br /> Installation will serve: Residence ["Apartment House [] Commercial [] Trailer Court [j Motel 0 Other [I <br /> Number of living units: Number of bedrooms Z.- Number of baths _2,__ Lot size .4-ol).(JIS, ---------------------------...... <br /> Water Supply. Public system 9--Community system [3 private F] Depth To Water Table -4-0 ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam Ll Clay Loam C] Clay E] Adobe Hardpan C] <br /> Previous Application Made: [if yes,date.-------------------I No GO"—New Construction: Yes �No [] FHA/VA: Yes 0 No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> [No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sept' T Distance from nearest well---__._-_-------Distance from foundation--------------------Material------------------------------------------------- <br /> No. of compartments-------------------- ----Size--------------------------------Liquid depth---------------- --------_Capacity-----------. -•i----- N <br /> I Distance to nearest lot line__i4-7--------- <br /> Disp all �_i Distance from nearest well-.:----._-_.-Distance from foundation---t*�----------- <br /> Number of lines_______... -_________________Length of each line.. -----------Width of trench---2ek---------- -----------­ <br /> Type of filter materia _ v_ --------Depth of filter material__/Z---------------Total length--------ZO./........---------------- <br /> Seepage Pit: Distance to nearest well.._` ------------Distang _Distance to nearest lot line <br /> cm founclation-_J4.......... --------- <br /> Number of pits--/-------------------Lining mate ria L..Ill---- Size: Diameter---YT-------------Depth----Z-�,r----------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation----_._.--_- -_-.Lining material_-.._-__-_--_-----..-_-------..-.--_ <br /> ❑ <br /> aterial------------------------------------- <br /> 1­1 Size: Diameter-------------------------------------Depth-------------- -------------------------------------Liquid Capacity----------------------------9 als, <br /> Privy, Distance from nearest well-----------------------__._----.---___._ .-__.__Distance from nearest building--------__-------------_------------ <br /> 0 Distance to nearest lot line----------- ---------------------------------------------------------------•------------•-------•----------•-• _--------------------------- <br /> Remodelingand/or repairing [describe)------------------------------------- ------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------I------------------------------------11----------------------------------1­1----------------------------------I---------------------- <br /> --------------------------------I---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------------------------------------------------------------------------------------­­-------------------------------------------------------------------I—--------------------------------- <br /> ----------- --------------------*---- <br /> I hereby certify that I have prepared ft appl�* anon and that the work will be done in accordance with San Joaquin County <br /> s the <br /> San <br /> ordinances, State laws, and rules and regu ions the San aquin Local Health District. <br /> (Signed)-------------------------------------------- --- ------- - -- ----- - ------------------------------- ------------------------------- -- ---(Owner and/or Contractor <br /> -- ---------------- ---- .. <br /> By----------------------............ - ------------------ ---- -------------------------------------I--------(Title)------------------------------------------------------- <br /> to <br /> to wells, buildings, etc., can be placed on reverse side). <br /> (Plot plan, showing size of lot.,location o ysf em in relation <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.____j---f--- _4&_1——------ ------------------ DATE--- ::n ----- --- <br /> REVIEWED BY--------------------------------------------- ---------------------------I--------------------------------------------- DATE...............- --- <br /> ---------------------------------------- - <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------—---------------------------__------ DATE--------_... -------------------------------------- <br /> AlferACflons an or recom cdr Voris------------ ---- ---------------- ---j <br /> ---.......--••------------ <br /> ........... -- ------- ------- - ........�� --------------------------- <br /> ---------------------------------- ---------------------------------- -------------------------------------------------------------­­------------------------------------------------- ------------------------------ <br /> --------------------------------------- --------------- ------------------ ----------------------------------------­1--------------- -------------------------------------------------- -------------------------------- <br /> ------------------------------------------------- -------- ----------------------------------------------------------------­­----------------­------------ ......................... --------------------------------- <br /> .... ---------- <br /> FINAL INSPECTION BY:--------J ........ - ----- --- - - --- --- Date--------- ...... --------------- <br /> ASAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> 1 <br /> Stockton,California -Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED B.59 2M 5.6Z ATLAS <br />