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I-UKUt-HCE USE. — <br /> r <br /> -------------------------------------------- <br /> ------------------ -------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. <br /> ----------------------------------------------------•---- (Complete in Duplicate) <br /> "-"-""-""""--------- --------------------- -------- This permit Expires 1 Year From Date Issued Date Issued __r� L_ f 'e-- <br /> Application <br /> t Application is hereby made to the San Joaquin Local Health District for a permit to construct a�d i 6M ork <br /> This application is made in cornpl.*ce with County Ordinance No. 549. c ascribed. <br /> JOB ADDRESS AND LO ATION_._..r.Y_ <br /> Owner's Name_ . . ....... ....... <br /> Address...------------------ <br /> - ------------------------•---------- --------------- <br /> --------------•-------------- Phone................-------------------- <br /> -----------1-• -- ��''_ <br /> --- -- - -- - ----------- - <br /> •-----•------•-----------------------------••- <br /> Contractor's Name___ __- <br /> ------ _ <br /> � .. --- ----•----- - --- -----•----------"-------••--------- ............. Phone....................... <br /> __________•-- <br /> Installation will serve: Residence © Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of living units: ` Number of bedrooms .A__ Number of baths J-___ Lot size . �`- -_ ❑ � `" � <br /> Water Supply: Public system E] Community system 0 Private�O Depth To Water Table .��_ ft. ; 1 <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam to Clay ❑ Adobe❑ Hardpan ❑?� �� <br /> Previous Application Made: {lf 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 Tank: Distance from nearest well _____Distance from foundation-----.-------------Material <br /> } o. of compartments ---------------- <br /> ----Size--.._--•-•------------------Liquid depth--------------------------Capacity <br /> isposal JFL y Distance from nearest well----iFQ-...Distance from foundation"""-•--- .......Distance to nearest lot1 <br /> Number of lines--------------------•------_---- Length of each line---/--------- <br /> -----------Width of french-----eZ7•_-'" <br /> Type of filter material-.e Depth of filter material___ Total length--- _.........______________--,"" <br /> Seepageit Distance to nearest well_-_- --------------aDistance from undation___jP <br /> ..........Distance to nearest lot line--l......""- <br /> Number of pits_-..�-------- "-"--Lining material__. -----Size: 'w <br /> -Lining Depth_I'�_ ------•---•---__-•-- <br /> Cesspool: Distance from nearest well________________ Distance from foundation----_______.__---".Lining material........----------------- <br /> •---- <br /> ❑ Size: Diameter Depth ------------------------------Liquid Capacity gals. 4 <br /> Priv -` <br /> Y- Distance from nearest well-.-.""__-:........ ................................. <br /> ___.--"....._.__... ...........""--Distance from nearest building <br /> ❑ Distance to nearest lot line"-__:.__-_---_______________"-""---"-""""--"-. <br /> Remodeling-and/or-repairing-(desc-r-ibe)- �_______--_-"- <br /> --------------------•------------------------------------------------------------ <br /> ----------------••---••---------•-------- ---------- <br /> ------------------------------------------------------------------------------------------------------------------- ---------------­......q---­----------- <br /> ------•---------•---------------------------•--------•-- -----------------------------------------...------------------------------------------------------------------------ -----------------------I-------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San"Jbaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> _ ._ __ __ - "40 <br /> -------- •------------------- ----- - <br /> (Signed) ____ ___________(Owner•and%or Contractor} � <br /> By: -----------•-------- •-------------------- --••- ----- - -• -- --- - ---- rifle _ _ __ __ _____ <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 . _ _ __ _ _ __" <br /> REVIEWEDBY------------------------------------- -----------------------------------------------•---------------•------------ <br /> ------------ DATE.-..----- <br /> - - --• - ------------- <br /> BUILDING PERMIT ISSUED-------------•-- -------- - -- - -- <br /> ,f-'----° <br /> DATE_. - .._..- -- --------------------------------------- <br /> Alterations and/or recommendations:__-___- <br /> r r --• -------- -�--'----------n-""" <br /> --------- - ------ ----•--"---- <br /> - <br /> : <br /> ------------ <br /> ; <br /> -•-----."----......."_-"-_"-----------------------------•-- ._.-.-" <br /> ---------- - <br /> ` <br /> -----•-•-------- --- ----------•-------- -----•-- --- <br /> FINAL INSPECTION BY: ----- ------------------ Date-// -,Z-/ ��.- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Stmt 124 Sycamore Street <br /> 405 West 91h Street <br /> Stockton,California Lodi,California Manteca,California <br /> Tracy,California <br /> ES 9 REVISED 8-59 ZM 5-62 ATLAS <br />