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FOR OFFICE USE: <br />--------------------------------- -- ------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. _ d./_ <br />------------------------ ------------------------------ (Complete in Duplicate) s/ <br /> ------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> 005— 145'-31 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> 3. <br /> This application is made in compliance with County Ordinance No. 549. _ <br /> JOB ADDRESS AN OCATION ._.. 'art K -c�- ''c' <br /> Owner's Nam � •-• - - - - - --- <br /> ' <br /> _Phone _- <br /> •te •• p <br /> -Address qGZ <br /> ---- - . <br /> Contractor's Name---------- --- -ti---; <br /> - <br /> ------ Phone.--F........................... <br /> Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Cour []/ Motel ❑ Other ❑ <br /> Number of living units: ._- -. Number of bedrooms .47_:;" Number f baths __ __ Lot�siza .___-_ _ _ :..................: { <br /> Water Supply: Public system ❑ Community system'0 Private (Depth To Water Table ____ ft. 1` <br /> Charac#er'of soil to a depth of 3 feet: Sand ❑''Gravel ❑ Sandy Loam 0 /Clay Loam ffr Clay ❑ Adobe❑ Hardpan ❑ter <br /> ;. Previous Application Made: {If yes,date_f---------------i . No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: J �{ - <br /> (No septic tank or cesspoolpermittedif public sewer is aveilable,within 200 feet-1 r <br /> X <br /> 3 <br /> Septic Tank: Distance from nearest well_________________Distance from foundation.--------------- _.Material-•_-___________.__.___------------.___________--. <br /> ❑ No.of com ar'tments-______________________ "Size...:........f�---:-----------Liquid de th__.___________.--.--- Capacity <br /> Dispos Field+ ,f Distance from nearest well _.`! __-_Distance from foundation.__jA)—_ + Distance to nearest lot line_...t�......... <br /> Pe <br /> Number of lines----------- Length of each--line-------#1 _41_________�f.Width of trench_____j�_______..____________ <br /> Type of filter material:��t ,____Depth of filter ma erial_-_-.--_11 ___ _.Total length--- „�____ ______________________ <br /> /` f� i <br /> Seeps a Pit: Distance to nearest well-----LQ_U____-__Distance from foundation_-...�.�.:.:__..plstance to nearest lot line_.............. <br /> ' V Number of pits__________ _________Lining material__!` 7.Size: Diameter._____ ..._-Depth__..__-5.�.______._.__._� <br /> Cesspool: Distance from nearest well-------------____Distance from foundation-----.---------__.Lining material------------------------------------- <br /> ❑ Size Diameter------ ----------------------- <br /> :Depth Liquid Capacity gals. <br /> Privy: Distance from nearest well------------------------------------------------_"Distance from nearest building_____.._.-._.--._-__._________.____.-____. <br /> C1Distance to nearest lot line----------------------------------------------------------------------- ----------------------------------------•---------------------------- <br /> Remode nig and/or repair' describe):------------- - `.... <br /> ------•-------- -------------------- -- -- -------------------------------------.....------------------------------------------------------------------------ -•----------•------------------------------------ <br /> I hereby certify tha+ I e prepared this application and that +he,work will be' done in accordance with San Joaquin County <br /> ordinances, State la , and ules and regulations of +he San Joaquin Local Health District. <br /> (Signed)------------ - --- ----------- ------- ---------------------------------­--------------------- --------------------(Owner and/or Contractor) <br /> By:..--- • ----- --...[Title} .--- •-------------------- ------ <br /> (Plot plan, showing size of lot, location of sys#em 'n rela+ion wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---,Z,/,-- - - - -------------------------------------------------------- DATE--- <br /> ------------------------------------------------ <br /> REVIEWED <br /> - -- - -6 ZREVIEWED BY------------------------------------------------------------------------------------------------ ----•------------------------ DATE-------- <br /> BUILDING PERMIT ISSUED-------------------------------------------------------------— DATE <br /> Alterationsand/or recommendations:-------------- ----------------------------------------------------------------.--__----•-----•-••---------•---------••---------------------------------- <br /> -----------------------------------------------------------•------•------------------- -•--------------......-. -..---•-------- ------------------------------------------------------------------------ -----.... I <br /> -----•----------------•----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------- <br /> ----------------------------------•-------•--------------------- ------------------------------------------- <br /> FINAL INSPECTION BY � ------- <br /> --------------------- Date ��� >� ----- <br /> SAN <br /> -`SAN JOAQUIN LOCAL HEALTH DISTRICT ;y <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street f <br /> Stockton,California Lodi,California Manteca,California Tracy,California j1 <br /> ES 9 REVISED 8-59 2M 5-62 ATLAS <br />