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FOR OFFICE USE: <br />-------- ------------------------------------------------ l 7 <br />---------- ------ <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit ....... ...: .. ... <br /> (Complete in Duplicate) Date Issued <br />-------------------------------------------------------- This Permit Expires I Year From Date Issued <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 No. 549. yc _ <br /> JOB ADDRESS AND LOCATION......�..�` a•--/•------------------- .....--7777-- 7777--•- <br /> Owner's Name-•------------•-----_----------•---•--•-------- -- ����`� ----- -----•---- Phone <br /> Address------------•---•-•-----------•-----••---------------- •... .------------------------------------•---------------......---------••--------•---------------••-•--------•-•---••---•---•----•-------•---•------- <br /> Contractor's Name---------------------------------------------------------------------------------------------------------------------------------------------- Phone.................................. <br /> Installation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _._/- Number of bedrooms .-/--- Number of baths ../_.._ Lot size .............•.-.._.-....-•.._-_--_--...__--_-•-.-..-------- <br /> Water Supply: Public system 2- Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Cl Clay Loam Clay❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date____________________) No 'New Construction: Yes ❑ No Ej_--FHA/VA: Yes ❑ 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 well---- r __Distance from founds#ion_ .©........Material_____ __----- __ <br /> d -• - _____ <br /> No. of Size dePth______ .•--7777•-Ca Capacity <br /> _..._.. 0..0 <br /> well__�_ __._..>r Distance from foundation.___.--.l. Distante to nearest lot line._____r!'.�Ct?. <br /> Disposal Field: Distance from nearest <br /> Number of lines----------••---/--------------Length of each line-------.--- --••- ..Width of trench..............?.rte.•-------- <br /> Type of filter material-_-_- S-Depth of filter material____/ .----Total length------------------6-•jo............. <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation__•_-_._.__..-__•--.Distance to nearest lot line............___-- �,'� <br /> ❑ Number of pits---- -----------------Lining material-----------------------Size: Diameter---_--•--------------Dept h---------_---__.---------- D <br /> Cesspool: Distance from nearest well._`r Distance from foundation---._ .4_...Lining material__._---.-_ <br /> Size: Diameter. De th----•--- -------Liquid Capacity---.....777--•7•----- gals. <br /> ,.�G , ..._ . p ------ <br /> Privy: Distance from nearest well--_________________;------.---------------------Distance from nearest building------------------------------------------ <br /> Distance to nearest lot line---------k ❑ <br /> - -------•---------------•------------------.._...._.. ------- � <br /> . . 7777-•77777777-- -7777-• <br /> Remodeling and/or repairing (describe):______. „ -- •-- - —�- <br /> r..__._... ..r�` .........--- <br /> --------------------------------------`�- -------------------------•----------------------•--------- �( I <br /> --.7777---7777-- 7777 - - -• -.--------•����..._ - <br /> �:�-.-.�.�.777 7--7777- Int <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 rules and regulations of the San Joaquin Local Health District. i <br /> (Signed)------------ ------------------•------------•-•---••--7777--- ---------------------------- ----------------•--------------------------------------- •-----{Owner and/or Contractor) <br /> - • - <br /> By:....------------------------------------------------------------------------------------------------------------------ <br /> ---------- -- <br /> Title <br /> ---------------•------------�--- --�-•-•�-�- -��- --- 7777..... <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FO PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------•------------------------------- <br /> DATE ,. <br /> REVIEWED BY-----------•------------------------------------------------------- ----------------------------- <br /> ---------------- ---------------------------------- DATE----------- ........ -------••---- <br /> BUILDINGPERMIT ISSUED---------------------- -------------------------------------------------­­---- DATE....--------------------- ---------------------------------- <br /> Alterations and/or recommendations:-------------- ----------- ----••--•------••-------------------------------------------------------------------------------------------•- <br /> --•------•--•----------------••----- ... -------•---•-------•--•--- --•----- <br /> < - <br /> FINAL INSPECTION BY:.... :1_._..` Date_........ '� ;-- 4_-m-------• ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Stroh 300 West Oak Street 144 Sycomom Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 6-59 21A a-61 ATLAS <br />