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FOROFFIC U E: <br /> t _ClAPPLICATION FOR SANITATION PERMIT Permit No. .--La <br /> --------------- -------------------------------------- (Complete in Duplicate) <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 LOCATION <br /> S ?_ _.---•-Q <br /> Owner's Name--- r e ..............................---•----------------------------------------------------- ----------------------------------- Phone------------------------------------ <br /> Address /-= :7 7_ �-----------------------------------------------------------------------------------------------•---------•-------------------------------- <br /> Contractor's Name......... ----------------•----------- ------------------------------------------------------••---------------------. - Phone-------•-----••-•-•---•------•---- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court El Motel ❑ Other ❑ <br /> Number of living units: -__-V. Number of bedrooms _.-_ Number of baths .1... Lot size ___.�.f�,x..,��._Q_•--_•-•••__________________ <br /> Water Supply: Public system VK116ommunity system ❑ Private ❑ Depth to Water Table _9.!� ft. <br /> Character of soil to a depth of 3 feef:'l Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2---Kardpan ❑ <br /> Previous Application Made: (If yes,date____________________) No New Construction: Yes ET"No ❑ FHA/VA: YeskFo ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> SepticTank: Distance from nearest well___! e.Distance from foundation-_e--r-______.Material. ----------------- / <br /> _ -_ -_------ Ca acit - QNo. of compartments------- Liquid depth....___ - .0--*4 <br /> Disposal Field: Distance from nearest well_Mcrz�___Distance from foundation-_/6..............Distance to nearest lot line...4 �.___._ <br /> 9 A:C -------------Width of trench...--....2.•-..::......... <br /> Number of lines_-_-- _________---- _______ <br /> _____ ____Len Length of each line______- <br /> P g <br /> Type of filter material_____ _ __ _ ________De Depth of filter material length <br /> Q:......._______.___.___.._ 4 <br /> stance to <br /> Seepage Pit: Nlumberr of rets res�e-l_�u pini -- material-- fir�f_o__ . Size: Diameter 3��toDneepthst lot <br /> Pig Q <br /> Cesspool: Distance from nearest well-----...........Distance from foundation..------------------Lining <br /> ❑ material..__..-_____-_______-----.--_-__._-___ <br /> Size: Diameter------ -----.Depth----•----------•-----­--­----------------------- Capacity....•-•----•----•-•........gals. <br /> Privy: <br /> Distance from nearest well------------------------------------------------Distance from nearest build ing__.._._.__________--_----_______-__.____.. + <br /> ❑ Distance to nearest lot line----------- -------•--------------------------------------------- <br /> •I <br /> Remodelingand/or repairing (describe) ----------------------------------------------------•---------------------••------------------•--------------••--------•-----••----------•-----•----•-- + <br /> ------------------•----------------•-------.................--------------------------------------------------------.-------------------------------------------------I..........---------...---_..-------------------------- <br /> ------------------------------------------- � <br /> 1 hereby certify that.) have prepare is a lication and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and .r g atio of the S n Joaquin Local Health District. <br /> ----- ---- - <br /> (Signed)------•-••----------------- -- ---- ---------- ------ -•- (Owner and/or Contractor) <br /> By: - ---- --------- -----•------------------------------------------------------triitle)------------------------------------------------- ---------•---- <br /> (Plot plan, showing size. of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> ff FOR DEPARTMENT USE ONLY f f / <br /> APPLICATION ACCEPTED BY-'/------- ------- ---- --- -----------------------•--------------------------- DATE-.-/-/-_ _ _.'x...61-------.------------- <br /> REVIEWEDBY--------------------------------------- --------------------------------------------------------------------------- DATE--------------------------- <br /> BUILDINGPERMIT ISSUED-,...... --------------------------------------------------------------------------------------- DATE-------------------------- <br /> Alterations and/or recommendations--------------- --------- <br /> �.J. y /` =— - � � ' -- ---------------- <br /> r.__ <br /> ------------- --- <br /> FINAL INSPECTION BY:._=_ -..,..-. --- Date------ -- ----- / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 Wast 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 0 REVISED a-59 2M 5-51 ATLAS <br />