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FOR OFFICE USE: <br />----------- ------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. _410.5....��..l <br />------------ -------------------------------- ----------- {Complete in Duplicate} <br />__ ___ _ _ ----------- -- --- This Permit Expires l Year From Date Issued Date Issued ___or?16.7� <br /> Application is hereby made to the San Joaquin Local Healfh 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 /> G _ a , <br /> p - <br /> r <br /> ". . <br /> _JOB ADDRESS AND L ATI one...... <br /> ------------- -------------------------- <br /> Owner's Name t • <br /> Address------ . . ---• --•------•-••---••-••-•-•. <br /> -- <br /> rC <br /> Contractor's Name.. " ----- ----••---._.-•------------- Phone................................... <br /> Installation will serve: Residence ( A artment House ❑ Commercial ❑ Trailer Court E] Motel ❑ Other ❑ <br /> Number of living units: -.1----- Number of bedrooms _�NumWED <br /> f baths ____1-. Lot size ------.._...__-- --------------- <br /> Water Supply: Public system ED Community system El Private epth t Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy loam Clay Loam [3Clay ❑ Adobe❑ Hardpan Q ` . <br /> Previous Application Made: (If yes,date---------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No El <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 /> ❑ No. of compartments--------___-----------Size---------------------------_,_._Liquid depth------------- <br /> ...------.--.--Capacity........_._.._.._._.... <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation-----•--.-.--._--_-.Distance to nearest lot line................. <br /> ❑ Number of lines-----------------------------------Length of each line--------------.---..------_;.V idth of trench....--•------------------------_-- <br /> Type of filter material-------------------------Depth of filter material-----------------------Total,length----------------------.-----..-..--------- <br /> e 1 Distance to nearest well------- Distance from fo ndation---t_4 -. <br /> ___.--; -/'4- <br /> __ DiSt'nce to nearest lot line....�a_--_- : <br /> -- <br /> Number of pits--------I------..__-Lining material-_-__.- .-_ - _.Size: Diameter- -.-- Depth------- <br /> .�_......... <br /> _----------- <br /> Cesspool: Distance from nearest well_-----_ -----_-Distance from foundation--------------------Liping material----------.----------------------- <br /> Size: <br /> -----_. -_.---_--.----Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid,Capacity-------._--...._.--.------.gals. <br /> Privy: Distance from nearest well--------------------------------------------------Distance from nearest building------------------------------------------ <br /> Distance <br /> ------.------.---_--_____-------..-----.Distance to nearest lot line-------------------------- ---------------------------------------------------= -'-----------••-----:--------------••-•-------------------- <br /> p 1 <br /> Remodeling and/or repairing (describe)----------------------------------"_Id, - - <br /> ---------•-----•-••---------------------------------- ---------------------------------------------- •---------------------------------------•----••--------•------------------ <br /> - _ - --------------------------•-•-•---------•-••-----------•----------•--•--------------. <br /> I hereby certify'that l'have prepared this application and that the work will be done in accordance with San Joaquin Coun <br /> ordinances, State I , and rules 4retions of the San Joaquin Local Health District.(Signed} r 1 {Owner end/or Contractok} <br /> ,.By:- �1-�-�'—��---- (Title}(Plot plan, sho ' g size of lot, locastem in relation to wells, buildings,etc., can be pace d'onreverservsid ).. <br /> 1 <br /> .FOR DEPARTMENT USE ONLY <br /> 0 APPLICATION ACCEPTED BY ----------------------- DATE---- a�t'f-.--..------- <br />', REVIEWED BY------------------------------.-.....--..-...-------------------------------------------------------------------------------- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED--------------------------------=-----•-••------------------•--------•--..-----•--------------------- DATE_.-------------------------------------------.-------------- <br /> Alterationsand/or recommendations—,­----•-----------{------------------------------------------------.-.....---.---------....-----------•--•---•-•.........................-................. <br /> r - . <br /> ,i -----------------------•---•-----------•-•-------•--•------ =------------ ----------------------------------•-------•--------------------------------- <br /> ---------------------------------- ----------------------------------------- ---------------- -------------------------------•-----------------------------------------•-------•-----------------------------------•--- <br /> ---------------------------------------------- <br /> '--------- ------------------------------------ <br /> -----------------------I.,---------------- -------------------------------------- <br /> ------------------------------------...-•--------------------------------------------•------•--------------------- -------------•-----------------------------•-----....-------------•••---•------------------•---•------------•------------------------------- <br /> FINAL INSPECTION BY:,A0Zv ��_ ---------------- 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 Tracy,California <br /> i ES 9 REVISED B-89 2M 5-61 ATLAS <br />