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FOR OFFICE USE <br /> �`/ rS q <br /> --- -------/--- - --`--- 3 5 <br /> APPLICATION FOR SANITATION PERMIT Permit No. .................... <br />------------------- (Complete in Duplicate) <br /> ----------------- -- <br /> I This Permit Expires 1 Year From Date Issued 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 LOCATE? _. .. ................................' r .4 ...... <br /> Owner's Name---- .lit -------------------------- �j �7 ` ,✓ Phone. <br /> Address----------------------- 1 -�--- <br /> Contractor's Name---------Z -1---------- ............................................ Phone......................••••. -•-•-- <br /> Installation will serve: Residence 0—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: J..-- Number of bedrooms .-j_- Number of baths J.... Lot size ._-��XJP2 p .----•-=- .•-- •••••. <br /> Water Supply: Public system [Gr'Community system ❑ Private ❑ Depth to Water Tableft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No e New Construction: Yes 0--No ❑ 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-.lh _ _Distance from foundation_/-Q`f?!� . Material-- <br /> [g` No. of compartments..----- --------------Size------ ........Liquid depth_.__,Or--------------....Capacity---9:G . T <br /> Disposal Field: Distance from nearest well.--210-e.-Distance from found atio46b ......Distance to nearest lot line................ <br /> [ZY Number of lines._.-----A-----------------------Length of each line..... .................Width of trench...... - y" - t <br /> . f ----- <br /> ..___.._...____._.._..Type of filter material_'�Aq_�-_-_------Depth of filter material_.1.K.�,...........Total length........I <br /> Seepage Pit: Distance to nearest wellA110-?'4_-------- Distance from foundation-o-V..............Distan'ce to nearest lot line .. <br /> 5 ...--.. <br /> Number of pits------- -.---.._----Lining material._"Ra.cAV-.....Size: Diameter...37...... _._Depth----------20 ............. <br /> Cesspool: Distance from nearest well...-------------Distance from foundation-------------•..._Lining material.__------ ----------------_-_---- <br /> 13 <br /> --.------_- -___---_❑ Size: Diameter--------------------------------------Depth..................-................-----------.....Liquid Capacity------------_-------------gals. <br /> Privy: Distance from nearest well ------._----_----------------------------------Distance from nearest building.......................................... <br /> ❑ Distance to nearest lot line----------------------------- ------------------------------------------...-----------...--------------........----......------ <br /> Remodelingand/or repairing (describe):.......................................................................................................................................................... <br /> ....................................---------------...............-.............................................................................................................-••••---•--••••-•----•-••-------­----------- <br /> -------------------------­W....:................................ <br /> ------ ----------------------------------------------------------••-••-•-••--••----••-•••--------•-••----•••......----•-•----•--••••--••----••--•---•---••-•-••--•••••--•---•--•-••------••--•-•••--•••••-•••••••-•--------•--------------_---- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------•---- ---•-•------------•-••----------------•---.. <br /> I hereby certify that I-have prepared this pli ation a d that the work will be done in accbMance with San Joaquin County <br /> ordinances, State laws, and rules and regulati n o the Sa Joaquin Local Health District. <br /> ............................:........(Owner and/or Contractor) <br /> (Signed) - - - ----------- <br /> BY:••-•••-•••-•••••••-••-•--•••••..w..................•••• ` ---------------------- -...............................-.............(Title)-------------- -------------- ------ <br /> (Plot plan, showing size of lot, location of sysi m in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR EPARTMENT USE ONLY L, <br /> APPLICATION:ACCEPTED BY...... ------------------------•••... DATE-----1--:_ .Y5 -------- -------- <br /> REVIEWEDBY------------------=--------------------------- ------ ----------------- ------------ ••-----•-•••......--.......... DATE.-----------------...-------•-------------.......---------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------=---=----_._----------------------------------•-•. DATE-----------------------------•----:------.------------------ <br /> Alterations and/or recommendations------------------------ <br /> ----------------------------.................................. <br /> -.................... <br /> •......... <br /> ..... <br /> -.............................................................................................. <br /> -.... <br /> ....................................... <br /> ...... <br /> ------------------------ ------...-----------------------------------------------------------------------------------------------------• ---------------------------------------------------..._------------------•..... <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------••••.................... <br /> -------------------------------------------------------•---•-------------------------..-.-.------------------ ---------------------...-----------------------------------------------------.--....--------•-------•-......----- <br /> FINALINSPECTION B .- -- -------- ---- ------ ---•----------_--- Date----- .......... ......... ................... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Strout 300 West Oak Street 124 Sycamore Street 205 West 9th Strout <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> B®•9 REVISED 0-69 F.P.CD.7M 6.60 <br />