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1-UR UFFIC USE <br /> ------ ------------- -------------- APPLICATION FOR SANITATION PERMIT Permit No. ....1. ............. <br /> --------- ------------------- --------------------------- (Complete in Duplicate) / 16 <br /> -------- --------- ----- -------------- -------- This Permit Expires I Year From Date Issued Date Issued ------ 2� <br /> ---------------- <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. 154 <br /> ----------* <br /> --- ----- <br /> Name_ <br /> --------------------- ---------- Phone...........------------------------ <br /> Address-..-- 4 0—A0 --------------------------- -----------------------------­-----Y_ <br /> --------- ....... <br /> Contractor's Name--- -- I---------- <br /> q�_._�4---------__ ---------------------------------------------------------------------- Phone................................... <br /> Installation will serve: Residence Eg- Apartment House E] Commercial E] Trailer Court C] Motel ❑ Other E] <br /> Number of living units: -A._ Number of bedrooms _25__ Number of baths _1---- Lot size ..... P <br /> -----------------_------- <br /> Water Supply: Public system .M Community system [-] Private 0 Depth to Wafer Table 2 ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam 0 Clay Loam ErClay E] Adobe[] Hardpan C] <br /> Previous Application Made: (if yes,date--------------------) No New Construction: Yes [3—No—L] FHA/VA. Yes [I No Eq— <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septi, ank;- Distance from nearest well_________________Distance from foundation--------------------Material <br /> No. of compartments------------------- ------Size-----•-•------------------------Liquid clep�k-------------------- .......... <br /> -----Capacity....................... <br /> Dis I I Distance from nearest well---------------..Distance from foundation-------------------Distance to nearest lot line._....__......... <br /> Number of lines-----------------------------------Length of each line-------_---------•--.-------Width of trench.--------------------- \ <br /> Type <br /> rench----------------------- <br /> Type of filter material-------------------------Depth of filter material---------_------------Total length----------------------------------------- <br /> Seepage it: Distance to nearest well-1.0--------------Distance _4qrn founclation-.4-0--1------Distance to nearest lot line/ <br /> Number of pits-----=�--------------Lining m ateria L- -----Size: Diameter---- ------------Depth------ ................ <br /> Cesspool: Distance from nearest well---------------..Distance from foundation--------------------Lining material__________..__---_-___ <br /> ❑ Size: <br /> aterial---------------------- <br /> Size: Diameter--------------------•-------------.-.Depth---- -----------------------------------------------Liquid Capacity--------------•-----........gals. <br /> I <br /> Privy: Distance from nearest well--------------------------------------------------Distance from nearest building_________-_._______--_______ . <br /> ❑ <br /> uilding--------------------------------Cl '"Distance to nearest lot line--------------------____. <br /> a <br /> r <br /> Remodeling <br /> ine------ -------------------Remodeling and/or repairing (describie):-------------- --------------------- ------------------------------------------------------------------------------------------------- <br /> -------------I-­-------------------_-----------------------I------ --------------------------*---------------------------­---------------------*---------------------------------------------••----------•----------- <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 rqg,ul ti? of A San Joaquin Local Health District. <br /> 0 <br /> (Signed)..--.------------------------------------------ <br /> ---------------- ---------------------------------------------------------- ---------------------(Owner and/or Contra f <br /> By:.................. c or) <br /> ................. ..... 17 <br /> ----- --------------------------------------- {Title)------------------------------------------------(Ti ------------------------------------------- - -- -------------- <br /> (Plot plan, showing size of lot, location' of system/in relation to wells, buildings, etc., can be placed an reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------C-------- --------------- -...........----------------I------------- DATE------- <br /> REVIEWEDBY--------------------------------- -------------------------------------------------------------------------------------------- DATE <br /> BUILDING PERMIT ISSUED---------------------------------------*-----------------------------*-------------------------­--- DATE----------- <br /> Alterations and/or recommendations:----------- -- --------------------- <br /> -----------------------------------------------------------------------------------------I-------------------------------­­-----------------------------------------------------I--------------------------------........ <br /> ------------------------------------------------I----------------------- ------------------------------­---------------------------­­­-------------------------------------------------------------- ........ <br /> ------------------------ ................................................... ------------------------------------------------------------------------------- ------------------------­.............._-------------------•-----------•-•-------...-._ --------------- ----------I---------------------------------- -----------------------............................................. <br /> FINAL INSPECTION BY:----- Date------ _Z_ <br /> ----------------------------------- <br /> ---------------- ------------------- ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Led[,California Manteca,Coliformra Tracy,California <br /> ES 9 REVISED B-59 2M 5-61 ATLAS <br />