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3 <br /> ----------------------- <br /> -------- 1 . -oL_ .._..._ ''�_3Q_ APPLICATION FOR SANITATION PERMIT Permit No. ..... <br /> f 3 <br /> .. <br /> --- (Complete in Duplicate) r . <br /> ------------- -------------------- ----------------�-- this Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to-fkb 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 ATION.._� ..'`3___P�_ __________------- -------------------------------------------- ................................................----------------------- <br /> Owner's Name t = �.� -- Phone........ <br /> -•--•--------------•------------------------------------• ----••....... <br /> Address------------------ � ` <br /> ..... # <br /> ----------- - <br /> Contractor's Name. {- --------- •- - - -- i Phone <br /> will serve: Residence�Ap`artment House'❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> f Number of livingunits: .. Number of bedrooms. . Number of baths _ -__ `-- r <br /> Lot size .._ Q... _� &2--------------•--------•- <br /> Water Supply: Public system V,16omrnunity system ❑ Private ❑ Depth to Water Table Y.-ft. <br /> Character of soil to a depth of 3 fee+: Send C] Gravel Sandy Loam ❑ Clay Loam E] Clay [j Adobe�ardpan ❑ <br /> Previous Application Made: (If yes,dote_-___.--_.__-.--_.- No ❑ New Construction: Yes ❑ 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 /> tic ankc Distance from nearest well-----------------Distance from foundation--------------------Material-.--_---_----_--...--__._............_.-_...-_... <br /> No. of compartments-------------------------r Size-----1-------------------------Liquid depth-----_- ------Capacity---••---............... <br /> l <br /> qsa d: Distance from nearest well------------------Distance from foundation-_-_---..---__----.Distance to nearest lot line................. <br /> Number,of lines.r--------_------------------------Length of each line------------------------------Width of french----------------------------------- <br /> Type of filter material-------------- . Depth of: filter material-----------------------Total length.................................. <br /> ._�..._ <br /> Seepage t: Distance to nearest well_ _1' .' _- -__:Distance m fgbndation....!V.............Distance to nearest lot line ....... <br /> Number of pits.._!__1----------- Lining material <br /> ��t --Size: Diameter-----��'-....._..Depth.-----�-a5...r..---••-----..._ <br /> Cesspool: Distance from nearest weldr-----------------Distance from foundation___-__-.-._....____. <br /> Lining material------------------------------------- <br /> ❑ Size: Diameter--------------------------------------De .fk',------------------- -'----------------------------= Li uid Ca aci <br /> tY-------•--•----------._._.._gals. <br /> Privy: Distance from nearest well_-----.--_--.----�_�_;--- ---------------Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot line----------------- -�` -•` =------' --------•--------•--- -----_-•-- <br /> ----------------------------------- ------------------------------- <br /> Remodeling and/or repairing (describe): # ,1 <br /> -------------------------------------------- ----------------------------------------------------------- <br /> !.1 1 <br /> i <br /> {, - _ <br /> ______________ _ _________________________________________________________________________-------------------------------- <br /> ________________________ .............._______________________________ <br /> ------------------•---•----------------------- <br /> q I hereby ify that I have prepared this application and that the work wilrl`be, <br /> done in accordance with San Joaquin County <br /> ordinances, t laws,.,andf79 les and gulations of the San Joaquin Local Health bis+rict. <br /> 1 <br /> (Signed) ----------- -------- -- ------ ------------ •-- <br /> ----------------------------- <br /> BY: <br /> --------------------------- _.(O,wner and/or Contractor) <br /> BY-----------------------------------------•-..._._...--•--� ----- -- ---- -------------...-----------------------(Titl�}---­-----------------------­- ......... ....................... ti. .. <br /> (Plot plan, showing size of lot, location of system in relation t ells, buildings, etc., can be placed on reverse side). <br /> t FOR EPART ENT USE ONLY y <br /> k APPLICATION ACCEPTED BY - ----------------------- DATE =< -� <br /> REVIEWEDBY-------------------------- .......•• ?------.- - ------------- - '--'- .,'."' ---• -•--------------------• DAT ----------------- <br /> v <br /> BUILDING PERMIT ISSUED__---=-------------•• •--._._.---, � � - ---------.. DA-TE---------------•--- <br /> Alterations end/or recommendations:- ._ - z_1-- --- s# <br /> ` 1 , -------+Z� ----------------------- <br /> ._..r _Q f -- --------�'-5._ -------•--•-----------•--•-•-------•---•---••--------- , <br /> •--------•--•----•-----------------------------------------------•... ",--------- <br /> l f <br /> ................................................... I---------------- -------------------- <br /> ------------------- ..._------------ -----•--•- <br /> FINAL INSPECTION BY:.-----C----s- 1 --------------------------------- Date-_.__,S ........._ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Strew 300 West Oak Strut 124 Sycamore Simet 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> A ES 9 REVISEb 8-99 9M 5-61 ATLAS <br />