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FO OFFI USE: <br /> X30,............../r f.----- <br /> ----- -------------------- ------ APPLICATION FOR SANITATION PERMIT Permit No. .. <br /> ------------------------ ----------- -------- -------- (Complete in Duplicate) <br /> ------------------------------------------------ This Permit Expires f-YE,ar From Date Issued 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__..__15__e_.- <br /> 4-- ----------------­----------- ....... <br /> Owner's Name-IIr�CJ..�_ �•_ <br /> ------- -•- -----------•--- Phone-------.---•.......... <br /> Address-------------- <br /> --- - ------ - <br /> Contractor's Name_.. '...... 00. ---- Phone-.44 <br /> Installation will serve: Residence Ap tment House ❑ Itom ercialrail <br /> Te Co <br /> ❑ f urt ❑ Motel ❑ Other ❑ <br /> Number of living units: .I---- er of bedrooms -------- Number of baths -------- Lot size . <br /> Water Supply: Public system PrIcommunity system ❑ Private ❑ De th To Water <br /> Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ be Hardpan ❑ <br /> Previous Application Made: (if yes,dpte-.....___----------) No El New Construction: Yes El No FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> o septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> is Tin Distance from nearest well.................Distance from foundation------.------------.Material <br /> ..-..-...._-.--..- <br /> of compartments-- ------------- Size._..----------------------------Liquid depth--- ----Capacity...-... <br /> D' sal Id: Distance from nearest well-kr _.._Distance from foundation..__44-`---.Distance to nearest lot line...... /® <br /> Number of lines.....--- •------------- - -- Length of each `-.---_----.Width of trench-....ate-$C«_ _ (� <br /> —i Tyle of filter material,� ./ i-pepth of filter material.... ,Oep°� <br /> I Total length...? <br /> Seepage Pit: Distance to nearest well......................Distance from foundation...........__.......Distance to nearest lot line..._....-.....-.. (� <br /> ❑ Number of pits------- •------Lining material-----------------------Size: Diameter._.-..-•---------------.Depth-------------------- <br /> Cesspool: Distance from nearest well................ Distance from foundation--------------------Lining material- <br /> ❑ Size: Diameter--------------------------------------Depth--- ----------------------------------:-------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well----------------- --- --._--Distance from nearest building <br /> ❑ Distance to nearest lot line- .------ <br /> Remodeling and/or repairing (describe)------- ------------------_ <br /> - <br /> ------------- <br /> -----------------------------------------------------------...-------•--------------------------------------------••------- --......... ---` <br /> hereby certify the I have prepared this application and that the wor will be done in accordance wit an Joaquin County <br /> ordinances, Staf aws, nd rules and regulations of the San Joaquin Loca Health District. <br /> 411- <br /> (Signed) ---------------- V-`'--- - ------------------ -----------------(09�ndfor Contractor) <br /> -----� <br /> gY� ----•-------------------------- --- - ----------(Title)-----------------•------------ ------------- ---- ----------- -- <br /> ------------ --- - - ---;- w <br /> (Plot plan, showing size of lot, location of system in relation ells, building etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------- ------F _-°- DATE-._. G <br /> . .. .... .............i-----..---------- <br /> ....... . ..............�....._. <br /> ...._.....-.... <br /> REVIEWED BY ----------------------------------------------------------------------------------•-------------------- HATE--- ----- <br /> BUILDING PERMIT ISSUED------------••----------------- <br /> ...-------------- --------- ----•--------- -------------- -• <br /> ------------------------------- <br /> I <br /> --------------=---------------- <br /> ------------------••--------------...--- DATE <br /> Alt era ion and/or recmendations:_- - ------------ <br /> _ - -- --- <br /> S -- ... <br /> - ----- <br /> .. ` -. r . <br /> .mit <br /> FINAL INSPECTION BY:.--� �- Date�---- Z <br /> 1-3-----•------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street <br /> 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California <br /> - Tracy,California <br /> ES 9 REVISED 8-59 2M 5-62 ATLAS <br />