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FOR OFFICE USE� <br /> �A- 17 <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br />- --- --------------- - -- ------------- (Complete in Duplicate) <br />-----------------.- --1.-I--....-M W M�M. I This Permit Expires I Year From Date Issued Date Issued ... Z_ <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 LOJ--ATION....101 ...........I------I..................................................................................... <br /> Owner's Name------ 10- ------------------------------------------------------------------------------------------------- Phone.................................... <br /> Address..............Ayjd...... ...........................................................7.......................................................................... <br /> Contractor's V.Name............440--!!..A JW-i-re-e- ................................... Phone............................----... <br /> ------------------------------------------ <br /> Installation will serve: Residence UpOlApartment House [] Commercial [] Trailer Court 0 Motel 0 Other 0 <br /> Number of living units: .-/... Number of bedrooms ..;*- Number of baths --/--- Lot size sav-4K..../J.620........................ <br /> Water Supply: Public system grootommunity system [3 Private [] Depth TO Water Table 400 ft. - <br /> Character of soil to a depth of 3 feet: Sand [] Gravel n Sandy Loam F1 Clay Loam C3 Clay [3 Adobe UPOI%rdpan 0 <br /> Previous Application Made: (If yes,date----------- --------) No [�New Construction: Yes 2--No ❑ FHA/VA: Yes [t.)/No El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic T nk: Distance from nearest we -------—-------Distance fr9,m foundation----1A.......M t <br /> ---------- -- ----------- ---------------- <br /> P;-ip No. of compartments.... ------- ---Size-jyp.2---440-m...Liquid dep.th.......rl- e5j,. /-------Capacity_- .._DQ.... <br /> Disposal Field: Distance from nearest well._._`-".._...-Distance from founclati n... / ....Distance to nearest lot line-ii:07—/.... <br /> Number of lines....../ each line...._ _. - 11 <br /> -------- -- Length of �A. . ........Width of trench.. .............................. <br /> 0,1�7.......................... <br /> Type of filter material4�tWjo�e.Depth of filter materi'al'---' ---..-.--._Total length <br /> 51-joy"-Depth <br /> Pit: Distance to nearest well__-_.'- ----.._.Distance �fro est lot line..... ...... <br /> Z fou ation.....24......Distance to near <br /> -.6 It/ <br /> aK Number of pits------/-------------L-ining material---------OZesize: Diameter--j?-----------Depth---,v-;:2;%... ................ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-......------------------.-.-__-----. <br /> ❑ <br /> aterial------------------------------------- <br /> El Size: Diameter---------------------------- ---------Depth-------------------------------------- -------------Liquid Capacity--------------------.------gals. <br /> gals. <br /> Privy: Distance from nearest well.................................................Distance from nearest building------------------------------------------ <br /> F-I Distance to nearest lot line-------------------------- -------------------------------------- ....... -------------------------------------------------------------- <br /> .................................................... <br /> .. .• <br /> ....... .. <br /> Remodeling and/or repairing (describe)---------------A&d <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------............. <br /> ............................................... ...............---------------------------------------------------------------------- ............................................................................... <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, and2oles and regulations of the San Joaquin Local Health District. <br /> I (fie''a +1e Contractor) <br /> (Signed)............... -- ------ -------- ------ ------------------------- <br /> ............(Title)...._ -------- ----- -- - <br /> (Plot <br /> ;V�-_ <br /> (Plot plan, showing size of lot, location of system in tion to wells, buildings, etc., can be placed on reverse side). <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------- --------------------------- DATE........e -------------------- <br /> REVIEWEDBY--- -------- ----- --------------------------- ------------------------------------------------------- DATE-------------------------=................................. <br /> BUILDING PERMIT ISSUED---------------------------_ --- --------------------------- DATE <br /> Alterations and/or recommendations:--/-? <br /> ............._;0------------- le...---'f ....... ............ <br /> ........................................I- <br /> ---------------------------- ------------------------------------------------------------------- <br /> ---------------------------------------- ----k-------------------------- <br /> ........................................................ ----------------- --------------------------------- ....................................................................0-J- -,,-,............... ...... <br /> ......................................................................... -----------------------------------------------------­---------------------------------------------------•-} .............. ----------------- <br /> ------------------------ --------------- ---------------------------------------------------------- ------------ ----------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY`0�.. --- ------------------- Date--- t- -7 — 6 Z-- <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 />