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FOR OFFICE USE: <br />---------------------- ---------------------------------- <br /> -------------- - -----------------_------------- APPLICATION FOR-SANITATION PERMIT Permit No. <br /> --------------------------------------------- (Complete in Duplicate) <br />---------------------------------- ------------------ --- I his re This P rmit Expires I Year From Date Issued Data Issued ...... . --- <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 /> f ?(.P <br /> 'on <br /> J6B <br /> ADDRESS ANb-ibtA__T-I 0 N <br /> A-4 <br /> Owner's Name_...--. -15l_C_K5.0-d-------------_----- <br /> ------------------------ -------------------------------------------- Phone................. ......... <br /> Address.......... -------------ZAT-HE F__!............................................ <br /> Contractor's Name---------- ------------------------------------------------------------------------------------------------------ Phone-------------- •--•-....._ <br /> Installation <br /> ........-Installation will serve: Residence Apartment House F] Commercial E] Trailer Court C] Motel 11 Other [] <br /> Number of living units: Number of bedrooms Number of baths <br /> Water Supply: Public system E] Community system Lot size /. 2------------- ------------- <br /> 4110'Private E] Dep <br /> th Water Table ./ ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel [-] S ndy Loam Loam ❑0 Clay [] Adobe 0 Hardpan <br /> Previous Application Made: (If yes,date------------------ ��New Const;uction: Yes ��/No [:] FHA/VA: Yes E] No <br /> TYPE OF INSTALLATIOWAND SPECIFICATIONS: <br /> (No Septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic nk: Distance from nearest well___,---... <br /> 10. c$_.Maferial................................................. 11Z_ <br /> T gero fou fion,_./W.,_ <br /> CTNo. of compartments-------------------- epffi'__1­­-----------------Capacity.............. <br /> �ti <br /> isposal Field- Distance f�o nea 11.....60._.Disfarice"from foundatio;64/40.-...-..',.Disfance to nearest lot <br /> fin e ..res w Width of trench---- �24M ------ C-3 <br /> Number of ------Length of each line...... ---- ------------ <br /> Type of filter �.4 <br /> _4, AD ID material j; ------Depth of filter material.._..__________Total length____-_--- ------------------------ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------;Distance to nearest lot line----------------- <br /> El Number of pits----------------------Lining material--------------------_--Size: Diameter--- ------------Dept h------------------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material_--__--________________-----.._.__-_. <br /> ❑ <br /> aterial------------------------------------- <br /> 1­1 Size: Diameter--------------------------------------Depth-------------------------------- -------------------Liquid Capacity_... ----------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot line----------------•-------------- -------------- --- <br /> Remodelingand/or repairing (describe):---------------------- ---------- --------------------------------------------------------------I--------------------------------------I----------------- <br /> ................................................................................ -------------------------------------------....... ------------------------------------ ••-------••---------------•--------------•--- <br /> 1!# .......---------------------------------------------------- ..............----------------------:------------i------------------------------------------------------------------------- <br /> ----------­--_--_----------------------------------------------------------------------------------------------------------------------------------------------------------......----------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Cc—, <br /> ordinances, State laws, and rules.and regulations of the San Joaquin Local Health District. <br /> $.1 <br /> --------------------------------------I-- -_1 <br /> -------------------------------------------------------------..-..(Owner and/or Contractor) <br /> By:-------------------------------- ----------- ------- <br /> ----------------- ------------------------------------------------------------------ ------------- <br /> (Plot plan, showing size. of lot, location of system in relation to wells, buildings, etc., can be�placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- tP,_0-------------------------------------------------­­­----------- DATE---------5-:!!7 7_1 6 71--- ---------------- <br /> REVIEWEDBY----------------------------------------------------------------- ----------------------------------------------------------- DATE--------------------------------------------------- <br /> BUILDING PERMIT ISSUED--------------------------------------------------------------------- ------------------------- DATE----------------------------------------------- <br /> Alterations and/or recommendations:---------------------------------------------------------------1-11,---------------------------------------........ --------------------­---- <br /> --------------------------•----•---•------------------------••-•-------------------------------------------------------------------- ---------------------------------------:­------------------------------- <br /> ---------------------------------------------I-----------------------------------------I-----------------------•-----•--------------_............---- - ----- ------------ --- ------------­----------------------------------_-------------------------------------------------------------- <br /> VN ........... <br /> -----------------............................. -- ----- ---------­--------- - --- ----- ------ - - --------------------------------------------------------------------------------------- ------------------­-- <br /> FINAL INS N B Date / __. <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 Lodi,California Manteca,California Traci,'California <br /> EA 9 61EVISED B-59 2M 5-61 ATLAS <br />