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FOR OFFICE USE: ! 77/ 76 <br /> r -- --------------- J <br />___________________ _*. _ ___-_--__._. PPLfCATION FOR SANITATION PERMIT <br /> Permit No. ...�.`�. .._3.�- <br />-------------------�.----- -.-.s---- -------- (__61' <br /> G-� � �� (Complete in Duplicate) ,,�rZ,��Z <br /> `� -- - This Permit Ex ires I Year From Date Issued 1 I/ Date Issued ....................... <br /> ` � � �., a <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construcl and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATEON_ , ��4,f,&4-(13,3 �5 rfiiv ._ rrl- 11t_, '�.Q <.!P�F _ r �� <br /> - ----�4- IWAV <br /> Owner's Name-- -• ---- 1. ----- •-- -------•------------------- Phone.................................... <br /> Address-----••------�..... ...--- = = <br /> ---•-----• . •--•-•.... Phone Contractors Name------ - •• --••------------------------------------------------------------------- •- -- - - - <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court 8<Motel ❑ Other ❑ <br /> Number of living units: '_ Number of bedrooms;'___ Number of baths ._/___ Lot size _YAM-1-�.'.................................. <br /> Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table 01% . d <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay,Loam ❑ Clay ❑ Adobe ff. ardpan ❑ <br /> Previous Application Made: llf yes,date--------------------) No U30' New Construction: Yes ❑ No [ HA/VA: Yes❑ No t <br />_f TYPE OF INSTALLATION AND SPECIFICATIONS: N <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) V) <br /> SP tic Ta k:" Distance from nearest well-----------------Distance from foundation-------------------Material....---------------------------------------------- <br /> �j6lri0* No. of compartments--------------------------Size---------------------------------Liquid depth--------------------------Capacity--------------__-- <br /> Disposal <br /> ----------•--..._. -Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest Jot line__-____-----_•.-- <br /> )!�5W5IW Number of lines------------•----------------------Length of each line-------•--------•--.-_----.._.Width of trench----.-- . .-•- _-----------_ <br /> Type of filter material.___________________--.__Depth of filter.material------`___-_____.____.Total length____......... .._.._._t___________..__-- <br /> SegpageL Pit: Distance to nearest well_- --_----Distance f om f undation__�'..__Disptance to nearest lot line_��s___-. C� <br /> �i �ry Number of pits--,,./ Linin material_xp�___._Size-.Diameter_.__Ole!i/--------Depth_____________________ <br /> Ces o 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 /> Cl Distance to nearest lot line--------------------------------- ------------- -- -----• . --•--- ------_-------------------- <br /> Remodeling and/or repairing (describe)--------------�'"a • <br /> •---------------------....•--••• , <br /> ................................ --------------- ....... ........ ........ •-- <br /> ---------------------•----.....- ................... -----....--••-------------•--•-------••-----•-------•---.._...--.1-_.__. <br /> --------------- -----------•------ ---------------•----•----------------------------------------•--•------------------------------•------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules nd regulations of the San Joaquin Local Health District. <br /> (Signed)-------- ��v - _ A. Contractor] <br /> By:-------------------------------------------- - ------ --- '-(Title)---- ------------ -------------------- <br /> (Plot plan, showing size of lot, location of system in relatio wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPORTMENT USE ONLY <br /> APPLICATION ACCEPTED ---- DATE-------Y__ -------(Iel. --- '- - <br /> REVIEWEDBY -•----.... ---•------------------------------------------------------------------------------------------------- DATE----------------------- ----------•----------------•------- <br /> BUILDINGPERMIT ISSUED-----------------------------------------------------------------------------------------------• •- DATE----------------------------------------------------- <br /> Aand/or recornmendations-----------------------------•----------------------•-----••-•---------------------------------------------------•-•--•-----------... <br /> ---------------• ----- ---- -------------------------------•---------•------•--•------------------•--•------------------------------•- <br /> --------- -- <br /> -------------------------•--------------------------------------------------------------•---••---..........--------------...----------_----•----------•........... <br /> -- •--------------------•--•--------...-----•--•-----------------------•----•-•-----•---•----------•------------ <br /> FINAL INSPECTION BY:. -.�:. � ''' - Date-------- h <br /> t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Strut 300 West Oak Srreei 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Montsca,California Tracy,California <br /> E8 9 REVISED 8.59 @M 5-61 ATLAS - - <br />