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FOR OFFICE USE: w <br /> 2---/-6 <br /> -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .z...... .._ <br /> (Complete in Duplicate) <br /> This Permit Expires i Year 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 AN LOCAT _S;121 ;-.3- <br /> p�i,Gt� <br /> --- -----••----••--------------•-------------------- ------------------------------ ---------------•----------•---••---• f <br /> Owner's Name- - ------ Phone...................... <br /> Address------------- <br /> -- -• -----------•---------------•--•--------------------------------- ------ <br /> -•..................•-------•- <br /> Contractor's Name -- •---•------- E � ------------------- Phone.................................. <br /> Installation will serve: Residence Apartment House [I Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: .__ Number of bedrooms __...Number of baths _... Lot size _j_<x_/9 ••-__-_--- <br /> Water Supply: Public system ln�community system ❑ Private ❑ Depth To Water Table .(a_p ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[Hardpan ❑ <br /> Previous Application Made: I I f yes,date--------------------) No U1 New Construction: Yes P9 No ❑ FHA/VA: Yes ❑ No E!I-- " <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank:* Distance from nearest well-----------------Distance from foundation------------_-------Material <br /> _____..__-_______._.___._.__.___...____..______.. t <br /> �.�, No. of compartments---------------- <br /> ----------Size--------------------------------Liquid depth--- <br /> ----------------------Capacity----------------------- <br /> Dispo Fi I Distance from nearest wellZ1t-A-.­'(--Distance from foundation. <br /> `,�_____________Distance to nearest lot hne__...._____.-.... <br /> Number of lines----_.-•f----•------------------•-Length of each line___-�--*------_-------Width of trench._P ,' ..`.:_____..----- <br /> �17 .._ <br /> Type of filter material-__.- !-"k___---Depth of filter material__�J�"_------------Total <br /> length__.._ '-fin_ <br /> Seep Distance to nearest well---- ---------Distant om found' <br /> tion__/q...........Distance to nearest lot line__.----- - <br /> Number of pits__I_ - ---•___---Lining materia___/e4QC-f ---- -Size: Diameter- •-`-f- <br /> ---------Depth-.-_A- ------------ <br /> Cesspoo: Distance from nearest well_________________Distance from foundation--------------.-----Lining material--------------_._______---____....___ <br /> ❑ Size: D•iameter-----I--------------------------.----.Depth---------------------------•------------------ Liquid Capacity gals. <br /> I <br /> Privy: Distance from nearest well __________--------------------------------------Distance from nearest building <br /> ❑ Distance to nearest lot line------------ ' <br /> Remodeling and/or repairing (describe):------------------------------------------,_-- I a <br /> ----------------------_--------------________________________------------------------------------------------------------------------------------------ f <br /> _____________................................................._______..__.......__.-------­------------------ <br /> ________________________________________________________ <br /> __________________________________________________________ ________„___-___--_________..______---___ <br /> I Hereby certify that I have prepared this application hat a work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules andlregulations of then at in Local alth District. <br /> (Signed)_ <br /> t <br /> ----...-----•--•--------------•---------------------------•---- ---- -------- t --- - - -- --------- ------------------L-----------------------------(Owner and/or Contractor) - <br /> BY: --------------- - -- --- - ----- --------- ---------- <br /> ---------------(Title)------------•--------• •---------------- ------------- - - ----- <br /> ---- - <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- _��_ Y- 6---------- ---------------------- -- -- - ----------------- DATE---- ------- <br /> REVIEWEDBY------••---------------------- -- - ------------------------------- - -- - --- DATE--------••---------•---•-------- -- <br /> UILDING PERMIT ISSUED---------------------------------------------------•---- ••------ ----- DATE---------------- <br /> Iterations and/or recommendations:-.t_ <br /> jt-----------------L------------------ --••--•--------------•---------•----------•-- - --- <br /> -------------------- - <br /> ----------------................. ------------------------ <br /> ---------- ------------------ --- <br /> v - <br /> FINAL INSPECTION BY:_.__- -^-_- - -- � �- <br /> - -- � . .- Date--------V .....- -------_1---- ­_6 - 3--- -------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Strut 300 West Oak Str*of 124 Sycamore Street 205 Wolf 9th Street <br /> Stockton,California Lodl,California Manteca,California Tracy,California <br /> ES 9 REVISED 8.59 2M 5-62 ATLAS <br />