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FOR OFFICE USE: <br /> ................ ------___................... <br /> ..........................-.t--------- APPLICATION FOR SANITATION PERMIT Permit No. <br /> --•----•-•-------••-•----------•--•----- (Complete in Duplicate) + <br /> Date issued <br /> ....... .......... I .......... ... This Permit Expires 1 Year From Date <br /> application is hereby made to the San Joaquin Local Health District for a permit0s,truc and install th work h ,� <br /> _This application,is made,in-compliance with County Ordinance No. 549. <br /> B ADDRESS <br /> ANDLO �e , D L._...._..._(. ._�'....._..¢off` t,rd� <br /> JOB ADDRESS AND LOCATION. _ _. r' n -��- .111_.___.____•.... _.. Z <br /> Owner's Nam ._ <br /> .- -----�!1L. ..4G.- - -- - •------------ ---•--- ---.........._........_.._..--........... Phone.------•---•--._.........-........ <br /> .. <br /> Address......... ------------ ------- _........_.. - <br /> Contractor's Name...- ............... . _-c 1.._...... Phone..........._...................._ <br /> Installation wig serve: Residence [jApartmen Nouse ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ........ Number of bedrooms Number of baths ----•--- Lot size --••--•------- -----•=---•••- <br /> Water Supply; Public system [3 Community system ❑ Private (2 Depth to Water Table ........ ft. -_ <br /> Character of soil to a depth of 3 feet: Sand E] Gravel F] Sandy Loam Eb Clay Loam ❑ Clay ❑ Adobe C] Hardpan C1 <br /> Previous Application Made: llf yes,dote........_ ........1 No ❑ ;New Con struction:'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.) 4 <br /> Spptic Tank: Distance from nearest well---- d Distan a from foundation----4.19. -1. material----- 11 .... 4. ......,.:, � <br /> No, of com artments. _Siz�yJe :fi�X_S__Li uid de th._._.__ Ca aei d <br /> P "IV -A I3� + . 9 P. ------ P ty. � ............ <br /> !� <br /> Dispol Field: Distance from nearest well.J.Q.0_ ..Distance`from foundation......LO......Distance to nearest log <br /> Number of lines........_._..--------___ '1-_ <br /> Length of each line........_ S.._......._._.Width of trench-...,Z__________------- <br /> __________ <br /> i <br /> Type of filter material...._._ ...._Depth of-filter material.....,��Y_.a_--------Total length------- ........................�� <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line-------A......... <br /> El Number of pits----------------------Lining material-___._...`-------------Size: Diameter.......................Depth--------------------------------- <br /> Cesspool: Distance from nearest well_____ -----_----Distance from foundation....................Lining material--------_-.__-.-_-_.._-_-___:..__.... <br /> ❑ Size: Diameter---- <br /> -------- -----=- ------Depth-=----.._....,.._................................ Liquid Capacity------•------------.-:.....gals. <br /> Privy: Distance from nearest }yell.....................................:...........Distance from nearest building-.............................__...... <br /> ❑ Distance to nearest lot line............................................. .......................I......................------------------------------------....._._., <br /> I ' <br /> R 1 (describe)------------------ . <br /> ......_..............----•...............................••-------------------------------•-------•---- ------•--•----------•-----_--•--••--•...........------.....---................................ <br /> t _ <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, S ate laws, and les and regulations of,+he Sen Joaquin Local Health District. <br /> I ; <br /> (Signed)..---- ------.. <br /> 'sy i '^' --.._ � r Contractor) <br /> ...-----•---------.•--- --- •...... ........ <br /> By: -G ,......... � ,}- ! (Title).-.._.. - I <br /> (Plot plan, showing size of lot, location of system in relatkin to wells, buildings, etc-, can be placed on reverse side}. ) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_. ----_._._.-------____-- DATE--- "._1r2..`..G_Z' i <br /> ------------- --------------•----•------. <br /> REVIEWEDBY------------------------- _ •---•--•----•...---------------------........ DATE------------.........------•--•------............ ...... <br /> BUILDINGPERMIT ISSUED.----------------- .._......_.-• ........._...._..-_-----------------------------........ DATE.----------------------------------------------- ---•------ <br /> Alterations and/or recommendations:.......___............ 1 <br /> ---------------------------------............................................._....._..._.............................................. ------­--------------.-.--.-..-.......----•----------------•------------------ <br /> •----•-----------------•--•---•••-•-----------•-................................................I....................................................................... i <br /> 4 FINAL INSPECTION BY Date.... ` --bv <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT., <br /> 130 South American Street 300 West Oak Street Com'' 124 Sycamore Street' '�, 205 West 9th Sorest <br /> Stockton,California Lodi,California Manteca,California j Tracy,California <br /> C8 9 R[VISLLO 8.89 8M 5•61 ATLAS F <br />