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F0R'O'FF16E U ' <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> ��-. _. <br /> --------- ----------------- ------------------ ------- (Complete in Duplicate) <br /> Date issued _-- <br /> - This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the Sdn Joaquin Local Health District for a permit to constr ct and install the work herein described. <br /> This application is made in compliance witli-County Ordinance No.-649. 51s� J <br /> JOB ADDRESS A/N�DCATION-- ./ed�--_- —------/ a f}�G --------------- --­------------------ <br /> Owner's <br /> •----Owner's -- Phone <br /> •------ <br /> Address <br /> � •- ---•-•---•--------------••--------- <br /> Contractor's Name------ ......-------•-•-------•------•-•---------•-------------------------••--------•------------•---- Phone-------_------------- ------- <br /> Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel [3 Other ❑ <br /> Number of living units: ./-- Number of bedrooms •,3--- NUmber of baths J__-_ Lot size <br /> _ ,p i •�----•--- <br /> Water Supply: Public system ❑ Community system [I Private C�epth To Water Table 101"Q ft. <br /> Character of soil to a depth of 3 feet:.' Sand E] Gravel F] Sandy Loam [IClay Loam [jClay E] Adobe R_�Vardpan ❑ <br /> {' ErlN ❑ . FHA/VA: Yes �'No ❑ <br /> Previous Application Made: (if yes,dcite----_------.__- 1 No � New Construction: Yes o <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 wellDistance from f/oundation__-h <br /> -•---- -.M trial P "�•� <br /> No. of compartments--.-- ----------------Size- --T�Q�--..Liquid depth:-..pe, �. . Capacity._ L -----•--- <br /> p ` i I <br /> 1�---_-__-Distance to nearest lot line................. <br /> Disposal Field: Distance from nearest well.-44— ---Distance from foundation_._ __ _. <br /> u f - g of each line---- r�` ff� Z� Width of trench-- '----••---------------•--- <br /> `Depth of filter material.__/-d__-------. Total length of lines---------�111------ Len ffi <br /> 4 S a s Pit: Distance to nearest well- < jP� Distant ' <br /> Type of filter material• . <br /> � I <br /> cep g e f om f ndation---_ ...._-_.DIst?ancs to nearest lot line__m'J-...... + <br /> Number of pits------Z-----------Lining material-/'�----Size:'Diameter---9.7_.--________Depth_�_47--------------------- <br /> r . <br /> poi: Distance from nearest well-----------------Distance from foundation-------------- Lining material---------------------------.......... <br /> Size: Diameter----- ----------------------- -------Qepth---------------------------------------------------Liquid Capacity---------------- -----------gals. <br /> i <br /> Privy: Distance from nearest well---------_-----------------___--------- ------Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot line------------------- ------------------- <br /> Remodeling and/or repairing (describe)---------- •---------------------- <br /> --------------........------------------------------------------------------------------------------------------------------------------ <br /> -------------- <br /> k: ----------------------•-------------••---••---------•--------------- <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 r es and regulatio s of the San Joaquin Local Health District. <br /> Si ned <br /> r Contractor) <br /> - - -- --- ---- - --- ------------- -- ---------------- ...- - -•- ----•---------------------- �-------(pyo or <br /> -- ------------- - - ---- - -- - ------------- <br /> -----(Tit <br /> (Plot plan, showing size of lot, location of system in relat' to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> c � / <br /> .APPLICATION ACCEPTED BY__=----All--- -- -- ------- ---- --------------------------------------- DATE--- ��/.- = <br /> REVIEWEDBY-------------------------- --------------------- ---- --------------------------------------I----------------- DATE----------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-------------•---------------------------------------------- --------------------------...--------:_ DATE--------------_- •-----------------------------•----------- <br /> Alterations and/or recommend'atio <br /> -- --------------------------- <br /> =f - ------------- <br /> • ---------- <br /> ---------- ------- YA----- <br /> �- ------ --- <br /> -------------------------------------------------------------------------------------------------------------- <br /> ------- -------- --------------------------------------------•----- --- ------------- ------------------- <br /> ' ® <br /> Date......1;7 --------------------------- •-----•-------.._. <br /> FINAL INSPECTION BY:------- ----------------- ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r er <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street :k <br /> Stockton,California Lodi,California - Manteca,California Tracy,California <br /> t ES 9 REVISED 8-59 2M 5-62 ATLAS <br />