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---------- -- -FOR O�IC1r USE: <br /> 5-�o%n----------� �`7 �/ <br /> lM APPLICATION' FOR SANITATIONF PERMIT Permit No. :..1 ....... <br /> x E <br /> ------------------ ----------------- - - ------------ -- (Complete in Duphcete) <br /> ----------- - _�- This Permit Expires 1 Year From Date Issued <br /> _ _________ Date Issued ---- -----•- b <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 /> I /fL ----------------------•-------------------------•---- <br /> JOB ADDRESS AND LOC�ATION /� � . C <br /> Owner's Name ................... - � Phone_1 .:. <br /> . •• - --------------- --------- ----------- <br /> Address-----•---------------•••-f-1- <br /> : �`�'` <br /> Contractor's Name........ `��E ---------------- ------------ --------- ------ ,{�`; i----• Phone................................... <br /> ------------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ ,Motel ❑ Other ❑ <br /> Number of living units:: _______ Number of bedrooms ________ Number of baths ._:___ Lot.size ............................................................ <br /> .{ , <br /> Water Supply: Public syste� Community system ElPrivate ❑ Depth ro Water Table _"'_. ft_ <br /> Character of soil to a depth lj f 3 feef: Sand ❑ Gravel ❑ Sandy Loam Q Clay Loam ❑ Clay E] Adobe Pg-'-Hard <br /> pan ❑ <br /> Previous Application Made: JjjIf yes,dote------------___-----) No ��lew Const rtuction: Yes to ❑ FHA/VA: Yes E] No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: -- <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> �f . t -- ftSe tiT k: Distance� rom nearest well-A! �istance from foundation__/_L'_____-Material.. _ - <br /> No. of compartments______..____��_____Size__��1 �_� .Liquid depth__.._...-��-______..CaPacitY- -�-� n-_-_-.- <br /> --- <br /> Disposal Field: Qistance:'Ifrom nearest well_ ___P.7'_-4—Distance from foundation...l_AL-.Distance to nearest lot line....` �._. <br /> !, / / <br /> Number of lines________________ ______ Length of each line_._____ .G__._I..Width of trench......Y` ..------------- <br /> Type <br /> _-_._______Type of filter material... G '4 -Depth of filter material __ /x�j__.!_.TotaI length----------"r G�_________________ <br /> Seepage Pit: Distance 'o nearest welL___________________Distance from foundation- ----------- to nearest lot line-------.......... <br /> ❑ Number of pits----------_•----------Lining material-----------------------Size: Disme#er--_--....--..----------Depth---------.•-----------.....---..- <br /> Iji <br /> Cesspool: Dis#ance;.from nearest well-----------------Distance from foundation----------_____-----Lining material__.____.__,._._______......_.__._.___ <br /> [] Size: Diameter-------------------------------------Depth--------------------- ----- 1 .Liquid Capacity_- gals. <br /> Privy: Distancel'from nearest well-------------------------k-----------------------Distance {ro lnearest building-----------.--------------------------- <br /> ❑ Distance!to nearest lot line----------------------------------------------- <br /> : <br /> Remodelingand/or repairing (describe):------ -----------------------------------••-•-•---------------•--------- -•--•--------------------------------------------------------- ............. <br /> i9_----------------------------------••----------------•--•---------------------------------------I••--------------------------------•---•--------------••--------------- <br /> --------------- -------------------- <br /> ---------------••-•----------------- ---------•- ----••---------••----------------_ -----••---------••--•..----------------------------------- ..-..----------------------------------------•-------------------- <br /> I hereby certify that I iia prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Stat la s, and I s and regulations of the So Joaquin Local Health District. <br /> (Signed, ti ------------------------------------------------------------------------------(Owner and/or Contractor) <br /> By: - - -------=--------- [Title] <br /> (Plot plan, showing size of lot, locafion of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> rl <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED�BY '�2 -- ----'"`�C_�----------- DATE <br /> REVIEWED BY---------------------- -------------J------ �--•-r- -DATE--------------------••----- <br /> ._.. RAE.BUILDING PERMIT ISSUED-------------------------------- ---•------------------ ---------- ----------- <br /> - _ firacmendation ,' �Alterations end/or . -� -------- ............ <br /> ----------­----- ------------------------ <br /> r <br /> --------------- <br /> ---------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY: ----------- Date <br /> ---------- ---------------•-------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Strut 300 Wad 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 /> A& <br />