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______________________ ____________ APPLICATION FOR SANITATION PERMIT Permit No. ..,� t�� - <br /> ----------------------------- --- 4------------------- (Complete in Duplicate) vDate Issued ____ 7W4 <br /> ---.-------------------------------- -------------------- This Permit Expires 1 Year From date Issued <br /> Application is hlreby 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._____..:T..' :___:`` <br /> Owner's Name----------- E•L✓ i✓-..•. + . <br /> 1/ � �,--o...�.-- ------- <br /> - --------•----•-�- -- � -• Phone_ <br /> Address. •--------- ---------------- ----------------------------------------------------------------- ---•-------•----•------------------------ .. <br /> Contractor's Name--- --------- .- -------------- <br /> "7 ------- '------------------------------------------- Phone................................... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> -__ Number of baths _f_... Lot size ------------------ U_ h _ ------- <br /> Number of living units: ___�__ Number of bedrooms __ _ <br /> Water Supply: Public system ❑ Commuriity system ❑ Private Depth ro Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (if yes,date--------- --------) 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 /> Septic T nk: Distance from nearest well-----------------Distance fromm undation-------------------.Material----_-.----_-_--_.__.._..............._......._.. <br /> No. of compartments-- ;; --�------------j%"--,Size-------- 'f'---------------•---Liquid depth ----------------------•-Capacity----------- --------- <br /> Disposal Field: Distance from ;nears t,well__---� ._Di arice from f�undation______IQ_ _.Distance to nearest lot line----------- <br /> Disposal 1. <br /> ❑ Number of lines------ ` ` ------------ ----Length of each line----_----- �O_.�--------Width of trench---_--_—2V..........._...... (✓1 <br /> Type of filter material. _-_ __-.-- D-e-th of filter i aterial--_-.--_-!$_`_`....Total length'____________________�Q_o t <br /> Yp P <br /> { 1 <br /> Seepage Pit: Distance to nearest well_r------------------Di fiance from flundation................-...Distance to nearest lot line---___._.__..__.. �u <br /> t ,ivf Number of pits---- ..._.._1----Lining material-..-----••-----1------Size: Diameter_--------_----.----_.:Depth................................. <br /> Cesspool: I Distance from nearest will_____._.____...-Distance from ffOundation--------------------Lining material----..--_-_.-----_-.--------___._._._ <br /> Size: Diameter_.____.__------ _ p ------Liquid Cap€city----------------------------gals. <br /> Privy: Distance from nearest we'll -: :- —_::_-_,_-_ _. _--_Distance from nearest building................................. ........ <br /> ❑ D Lance to nearest lot lin"e-----------------------------------------------------------------------------------•-----------------------------­­--------------•-------- <br /> Re. odeling a /or repai in descr• e) ------ -------------••---------------- ----------------•--------- -------{-----------------------• <br /> - = ----------- --•.• L <br /> ...................------•-------------------------------------- ----------------------------------------- <br /> -----------------------%-------------------•----------------•---------- •-------- ; <br /> I hereby certifythat 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 regulations of the San Joaquin Local Health District. <br /> F � <br /> r <br /> (Signed)-------- -- -----------•----------------------- --------------------------------------------------------------------------------------(Owner and/or Contractor) <br /> By:-- kl l G �-~ (Title)------------------------------- -------------- - -----..-------- <br /> (Plot plan, showing sire of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> DATE- / --------------- <br /> APPLICATION ACCEPTED BY-------------_---------__._-__.___-_ .;._ _. _ ._ <br /> REVIEWEDBY---------------------------- ------ DATE-- ----•-------- ----------- ----------------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------------------------.....------------------- <br /> Alferatiorisand/or recommendations:-------------------------------------- ---------- ............................................... -------.-------•----••-------------------=_-•---------- <br /> �. J <br /> - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------••........................•---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------ -------------------------------•----------------------------------------------------------------------------------------------------------......----------------------------------------- <br /> ------------------------------------------- ---­---------------------•--•---•----------------•----------------•-----•-•----•--------------------•--•-•-•----••-----------------••-•-------•-----•-------••••---------------- <br /> FINAL INSPECTION BY----------------------- -(-- ---------------- ----- Date--------.. .. . ''G---------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 2M 5-62 ATLAS <br />