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FOR OFFICE USE: <br /> - ----------------------------- - ------------------------- <br /> ----------------------- ------ ------------------------- APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> --------------------------- -- ---- ----------- -- (Complete in Duplicate) <br /> ----------------- Date Issued <br /> --------I--------- ------1--------- --- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to ton tract and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. -j ` \f- <br /> % e 7J 69 <br /> JOB ADDRESS AND LOCATION.. �fl 4 <br /> ,q/ -t <br /> ,eq 6�r <br /> - -------------- <br /> - ---------- I........ <br /> Owner's Name --- ...I-------- <br /> -------- ------_----------------------- -------------- --------------------- Phone------------------------------------ <br /> CC <br /> Address__.. -2 7 <br /> ......... <br /> ...1_7....... <br /> . QAC....... <br /> _ 11, --V-:............................................................................. <br /> ... . <br /> Contractor's ------------------------------- <br /> Installation will serve: Residence Apartment House E] Commercial Rj/ Trailer Court 0 Motel El Other El <br /> Number of living units: -------- Numb;r of bedrooms -------- Number of,baths -------- Lot size --- <br /> Water Supply: Public system [] Community system F1 Private Z-_'Depth TO Water Table !�e,ft. <br /> Character of soil to a depth of 3 feet: Sand [T Gravel D Sandy Loam L] Clay Loam [-1 Clay [I Adobe 0 Hardpan 0 <br /> Previous Application Made: (If yes,date--------------------) Nopa"'-New Construction: Yes PT'_'No E] 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 /> Septic Tank- Distance from nearest <br /> - -----------Distance from foundation----1—,'7--- <br /> No. of compartments.........P—--------.-Size-3�_9'K-5---------...Liquid depth_____ T_ Capacity_gl? Gsl <br /> Disposal Field: Distance from nearest well__- Distance from foundation----6�-�.........Distance to nearest lot <br /> Rl— Numb"*Erlin—e—s --------/---------------Length of..each line----------------------- <br /> qr ------.Width of trench--- !Z...... ............ <br /> Type o$f filter Depth of filter Waterial_____/,�?---------Tofal length............4-,�5------.............. <br /> Seepage Pit: Distanc'e-fo'nearesf-well--------------------- Distance from foundation............-------Distance to nearest lot line__....._._____.._ <br /> ❑ <br /> ine----_---------- <br /> El Number of pits---_-----------------Lining material.----------------------Size: Diameter------------------------De'pf h--------------------------------- <br /> Cesspool: Distance'from nearest well_________________Distance from foundation------------------- Lining material.._-______.________._________---. <br /> ❑ <br /> ateri;l--------------------------------­ <br /> El Size: Diameter-------------------------------------..De th--------------------------------- -----------------Liquid Capac I ity-----------------------_--gals. <br /> Privy: D isfa nce-from,nea rest-well_ --------------------------- -------Distance from nearest building-_-_----________.___-.-_______.__..___---. <br /> ❑ Distance <br /> uilding----------------------------------------- <br /> Distance to nearest ]of line <br /> •- <br /> Remodeling and/or repairing [describe)-- ---------------------------------------------------------------------•----------.--•-- j <br /> ...............--------------------- ---------------------------------I-------------------------------I--------------------------------- -------------------------------- ........----------------------- <br /> ---------------*----------------------- <br /> ------------------------------------------------------------------------------------------­----------------------------------------------------------------------------------------- -------------------------------- <br /> ------------------------------------------------------------------------------I——-­----------------------­I---------­----------------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepared this,;pPlicaflon 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 /> [Signed)- ------------------------------------------------------------ ----------(Owner and/or Contractor) <br /> l3y­:—..f <br /> ---------- <br /> -------------- -- ------- <br /> * Y <br /> (Plot plan, showing size of lo W <br /> t�ocaflon of system in relation to wells, buildings, etc., can be placed on reverse side).FOR DEPARTM,5NT USE ONLY' <br /> ACCEPTED BY -/ DATE----- <br /> APPLICATION AC Zd <br /> ---4A—aw -�-1 <br /> REVIEWEDBY-----_----------------------- ------------------------ ------ --------------------------------------------------- DATE------- <br /> BUILDING PERMIT ISSUED---------------------------------------**-----•----------------------- ------- ------- -------- DATE.--------------------........... <br /> Alterations and/or recommendations:..--- ----------- ------------------ - - <br /> ---------------------------------------- -------------------_ ------------- -----------------------------------------------------------------------------------------------------------------­----------------------------- <br /> ­­------------------ - --------------------------------------•----------1--------------- -------------------------I-------------------------------I.,-------------------------------------------------------- --------- <br /> ------------------------------------ ---- - -*-------- --- ---------- --------------------------------------------------------------------------------------------------------------- <br /> -----------------------------:�-- - - - ----- - ------------- ----------------------I------------------------------------------------------------------------------------- <br /> FINAL INSPECTI Date-------al. 0149-3-_-------------------- <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 8.59 2M 5-62 ATLAS <br />