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FOR OFFIC <br /> ------- -- -- <br /> V - APPLICATION FOR SANITATION PERMIT <br /> Permit N0. ..17..7_...(.... <br /> . <br /> .......... ------- _0­6:�------1 � <br /> 0 <br /> (Complete in Duplicate) Date Issued � /� <br /> ------------4-1A- ------------------------------ I 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. <br /> JOBADDRESS AND LOCATION.............17../S-__.-____-- ...... ......................................................................................... <br /> Owner's Name..........A/1 t <br /> ............. --------------------------------------------------------------------------------------- Phone.................................... <br /> Address---...------ 1 --•-•-... <br /> .................... <br /> Contractor's Name---------------A-/../­�"r.4�........... Phone.&.1!..�14 <br /> Installation will serve: Residence ff-Apartment House E] Commercial E] Trailer Court ❑ Motel [I Other [3 <br /> Number of living units: -__I_.. Number of bedrooms .2__ Number of baths ..I---- Lot size ......... .................... <br /> Water Supply: Public system 0 Community system [:1 Private F] Depth TO Water Table ........ ft. <br /> Character of soil to a depth of 3 feet: Sand [] Gravel F] Sandy Loam E] Clay Loam [] Clay 0 Adobe Hardpan 0 <br /> Previous Application Made: (If yes,date---I-----------.-..) No [B- New Construction: Yes Ef No [] FHA/VA: Yes [I No [I <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (Ijo septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septia 0: Distance from nearest well-----------------Distance from foundation--------_----------Material................................................. <br /> No. of compartments--------------------------Size............................---Liquid depth--------------------------Capacity....................... <br /> Disposalielcl: Distance from nearest well_________________Distance from foundation....................Distance to nearest lot line.._.............. <br /> ENumber of lines-----------------------------------Length of each line..............................Width of trench-___--_.__.._...................... <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length........................__............_... <br /> 0 (A <br /> Seepage6e Pit: Distance to nearest well- A&I?--- -----Distance from foundation---P��._........Distance to nearest lot line...--s.---- <br /> -------- <br /> i4, Number of pits-----------/----------Lining material---he_L A-------Size: Diameter__.-; A...........Depth-------4.1.1................. <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material...____..._......_....._..__._....... <br /> 0 Size: Diameter-----------------------------------_Depth----------------------------------------------------Liquid Capacity............................gals. <br /> Privy: Distance from nearest well----------------------------------------- -------Distance from nearest building------------------------------------------ <br /> 11 Distance to nearest lot line------------------------------------------------ -----------------------------------------------•----------•-----------------•--- <br /> Remodeling <br /> ine.---------------------------------------------------------------------------------------------------------------------------------Remodeling and/or repairing (describe):-------------------------------------- ................................................................................................................. <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------ <br /> ............................................................................................................................................................................................................................. <br /> --------- ---------------------------------------------------------------------------------------------------------I......................................................................................................... <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. <br /> (Signed)............ --•-------------------(Owner and/or Contractor) <br /> ­------------ <br /> By:------------- ------ ------------------------------------ ----------------------------------------(Title)---------------------------------------- ----- -- ---- --------- <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 /> APPLICATION ACCEPTED BY-------------------------------------- --------------------- ---- 5 DATE........... <br /> REVIEWEDBY--------------------------------------------- -------------------- ..... DATE........................................................... <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------ ... DATE............................................................. <br /> Alterations and/or recorrirendations:---_---------0............. .... -----------­---------- <br /> ---- ....... ...................... <br /> ........ ------------------------------------------------------------- ------------------------------------------------------------- ...............................�)....................... <br /> _ _ -_ _;, Q.. . . ......... <br /> ...................... .......... -----------_------------------------- ------------------ ------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- ------------ -------------------------------__-------- --------------- --------------------------------------------------------- ........---------------------------------------------- <br /> FINAL INSPECTION BY:...ji�------ - ----------------------- Date------- -------­-- <br /> ----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 2M 5-62 ATLAS <br />