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FOR OFFICE USE: <br />--------------------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No.1*10.1117......... <br /> (Complete in Duplicate) Z� <br /> 7 Date Issued <br />-----------------------________________------------------ This Permit Expires 1 Year From Date Issued .:� � �r;2-11 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. L� <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION.-_113-Z/------ _2r! ••----y�------------- ------------ -- • - - --•-------------------•--------------------•-••---- <br /> Owner's Name._.. ------------ = Phone-•---------_------------------• , <br /> - .... = .... ------------------------------------------•----------------------------:n---------------------- <br /> .Address-- `S T-S - Phone.......................--•-•- <br /> Contractor's Name......... - <br /> Installation will serve: Residence W— Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __j___. Number of bedrooms J.__. Number of baths _:J.__ Lot size .... ........................... <br /> Water Supply: Public system R' Community system ❑ Private ❑ Depth to Wafter Table :��eft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑f Hardpan Q,� <br /> Previous Application Made: (If yes,dote--------------------} No. eqr�'New Construction: Yes M—No ❑ FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> p -_--.Material------------------------------------------------ <br /> No. <br /> .-•--••------------- •••-------------------- . <br /> (No septic tank or cesspool permt+ted if public sewer is available within 200 feet.) <br /> t SP ti a <br /> Distance from nearest well_________________Distance from foundation.______ ____ <br /> �(,�• No. of compartments----------------•---------Size-------------------------- Liquid depth--------------------------Capacity---------------.------ <br /> Disp al Foe d� Distance from nearest well---------_-------Distance from foundation--__________-_-.__Distance to nearest lot line..______-------_ <br /> � + Number of lines-----------------------------------Length of each line......------•-•-----__------Width of french----------------------------------- <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length...................----------------------_ <br /> Seep�age Pit: Distance to nearest well-e------ "_______Distan om founda#ion___0.. �-------.Distance to nearest lot line___ �_.___,-t�- . <br /> 1. <br /> L� Number of pits....../------------Lining ---.Size: Diameter------31(-`----- Depth--------.7i-LS7.!__----- <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material..................................... <br /> ❑ Size: Diameter--------------------------------------Depth--------------------- ----•------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_______________--•_•-_-_-__________ <br /> f ❑ Distance to nearest lot line-----------------------------------------------------------------------...... ,--------------- --- - <br /> j - <br /> R modeling and/or repairing (describe):____ _ _______ _r __ �. Ca-alt ,-�.,2 <br /> -------------------------------------- ------------------------------------U--­-------r--------------------------------------------------- <br /> ------------------------------------------------------------•-------...- -----•-•-----------------------------•-------------------------------------------------------------------------------------------------------- <br /> I hereby certify tha+"I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I ordinances, State laws, and rules and regul tions of +he San Joaquin Local Health District. <br /> k y <br /> -------------------------------------------------------- --------Owner and/or Contractor <br /> By:---------------------------------------- -- ....... ----------------------------•-----------------------•--------------•----(Ti+le)------------------------------- ------- - ------ ------- <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 <br /> :. <br /> APPLICATION ACCEPTED BY------- --------------------------- DATE-------- - ---------------- <br /> sREVIEWED BY----------------------_----- -------------------•--• ----------------.------ DATE <br /> BUILDING PERMIT ISSUED----- --•----•----------------------------------- _ DATE---- <br /> AFFera+ions and/or recommendations:___-r.- -_�_ __.._ -- +---••-••••---- <br /> t -•••---•---••--•-•••-•------------ -------------------------------------------------- •---------------------------•------------------------------- --•----------------------------------------------_ C <br /> I ...•------------•----------------•-•---- .............-------------------------------------------------------------------------------------------------------•---..-•-••-•------•- --......-•-•-•--...-.----------- <br /> -------------------------- <br /> FINAL INSPECTION BY:.. �:I/� ��:.6�.�--= Date------------� �:---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> /J/ISED 8.59 2101 5-61 ATLAS ' <br />