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--------------- APPLICATION FOR SANITATION PERMIT Permit No. _ <br />--------------------------------------------------------- (Complete in Duplicate) A&A--6- <br /> ------------------------------------------------------- <br />-- This Permit Expires 1 Year From Date Issued <br /> 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 <br /> JOB ADDRESS AND LFCATION. . ,/ �-�_d......-_.- - --------••------------------------•-------•--------------------• " <br /> Owner's Name----__---- <br /> -- •-•---,/- -•- ••- ---•--- -- - ------------- Phone__._....----•----•-- <br /> -- - ------------------------------------------------------- Phone <br /> - ............................................................. - ------------ <br /> -- - ------------- <br /> Contractor's <br /> ----------- <br /> - -------/---/ <br /> Contractor's Name �, Phone.. ... 4d. •�b/� <br /> Installation will serve: Residence �rtment House ❑ Commercial ❑ Trailer Court ❑ telp Other ❑ <br /> Number of living units: Number of bedrooms __umber of baths Z____ Lot size ....... ................... <br /> Water Supply: Public system [ Commuriity system ❑ Private ❑ Depth to Water Tablt � ft. <br /> Character of soil fo a depth of 3 feet: Sand ❑ Gravel [:] S y Loam ❑ Clay Loaroo <br /> C] Adobe Q/FAardpan El <br /> Previous Application Made: {If yes,date--------------------) No New Construction: Yes FHA/VA: Yes ❑ No 3­1 <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_________________Distance from foundation---/5J__--------- <br /> Maf9rial____ ?....___..... <br /> No. of compartments..__�_______________Size____�b---.2r_�__�----Liquid depth----1,1��------------Capacity...ZO ........ <br /> Disposal field: Distance from nearest well-----------------Distance from foundati _ 4__�.__.__Distance to nearest lot line. g—/....... <br /> Number of lines-----------------/-_---____---_---Length of each line....._---•0_.-____-___-.__.Width of trench__�_e_�_______•_-___--•- <br /> fj r <br /> Type of filter matenal._.AZ_.i�S.K__Depth of ftl aterial It _,._____-_.,_Total length-_-_•----__�V.1____________________ L1� <br /> D l ` <br /> Seepage it: Distance to nearest well----------------------Dist, came 'rom fou cEation_l___.._______..Di tante to nearest lot iine_�?..__.___.. V� <br /> Number of pits_________ _Lining __Sizer Diameter____. , * Depth........ .......... <br /> Cesspool: Distance from nearest well...............••D stance from undation-----.--------------Lining material..................................... <br /> El Size: Diameter----------------------------------- -De ..-..-----------------•- Liquid Capacity---------------•---_------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot line-------�----i------------------------ -- <br /> /----------------------------------- --------•---.-_-------------•--------------------------------------- <br /> Remodeling and/or repairing (describe):--------------••- '� ---'z"� ---- ---- ---------- ------------------------•---•-------•---a 'V <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 law d rules a egulati s of the San Joaquin Local Health District. <br /> (Signed)----------------- ....... --------------- ------------- ------------------- ---Owner an or Contractor <br /> By:............................ -- -- --- ------ - ------------- --- ---------------------------(Title)---- - -- <br /> (Plot plan, showing size lot, loc ion of system in relation to we sl s,buildings, etc., can be placed on reverse side). <br /> FOR D PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- --------------------------------------- DATE---/-.-_L ------w- <br /> REVIEWEDBY----------------------------------------------y-------------­----------- ----------------------------------------------•--- DATE----------------------------•------------------------------- <br /> BUILDINGPERMIT ISSUED----------------..............................................--------------------------------------- DATE-------•------•------•--• ------•-•------------------------- <br /> AFterafions pndlor reco mendations__________________ ____ ... ..... <br /> 1 - <br /> -- -'-- f` -- �---- -- -- C ------ ..�. <br /> ---------------------------------------------- ----•-------••--------------------------------------------------------------------- ----------------------F----------------------------------- ........... <br /> FINAL INSPECTION BY:.--- r ----- ---------- Date---------1------ }. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT R <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street t 205 Wast 9th Street <br /> Stockton,California Lodi,California Manteca,California /y Tracy,California <br /> ES 9 REVISED 8-59 2M 5-61 ATLAS <br /> �,r � Fi.v.v ,c.. 1,e, �!7'✓ �r <br />