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FOR OFFICE USE:. <br /> _______________________ _________________________________ f.y� <br /> Permit No. .... <br /> ---------_- -----_--- - ------------------- APPLICATION FOR SANITATION PERMIT 1 - <br /> --- --------------------------------------- -------------- (Complete in Duplicate) Date Issued <br /> -------------------------__.._.___-_______--____.___.__ This Permit Expires l Year From Date Issued / S-0,.1-0-0 Ll <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein des rbed. <br /> VFOPli_ <br /> cation is made in compliance with County Ordinance No. 549. ----� I;f <br /> JOB ADDRESS AND LOCATI N.............. Z - �----- <br /> Owner's Name------------ /...---•--•. - Phone <br /> AddressC ----- ---------- ------------- -- '------------------------•-•---•--------•-•---------•----- <br /> C <br /> Contractor's Name----------------------------- ----------------- -7�------------- ---------------------------------------------------- -_------------- Phone-------_----------- <br /> Installation will serve: Residence [E] Apartment House Commercial [3Trailer Court ❑ Motel ❑ Other ` <br /> Number of living units: -------- Number of bedrooms -------- Number of baths ....____ Lot size _...____._ .rte �.-k-�-�-�,.-��-••-----•- <br /> Water Supply: Public system 2--community system F-1Private ❑ Depth To Water Table 'ft. yI <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑�Iay�Loam ❑ Cley ❑ Adobe❑ Hardpan ❑ i <br /> Previous Application Made: (If yes,date--------------------) No &­114-ew Construction: Yes Q--Nb ❑ FHA/VA: Yes ❑ No 9- <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 1 <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 3 <br /> Septic Tank: Distance from nearest well----- ............ <br /> Distance from foundation---/-s�-____--__.M(terial__/_ -----"": �. <br /> No. of compartments--------------L ----Size------,�'_113Y_oLiquid depth------�'--------------Capacity......-�'�...: <br /> _ E� <br /> Disposal ield: Distance from nearest well----- `__---.Distance from foundation__ �- ...__.Distance to nearest lot line----------__.. (� <br /> Number of lines_______________ _- Length of each line------------__:On- _Width oftrench----------- ,_.._______ <br /> _._ - <br /> Type of filter material.-4Z--- <br /> Depth of filter material___ r <br /> -. Tofial length---------------a____------------------ ; <br /> Seepage Pit: Distance to nearest well---------------------- from foundation-----------.........Distance to nearest lot line_______--__-____. <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------...-............Depth---------------------•----------- <br /> Cesspool: Distance from nearest well----------------- from foundation-------------------.Lining material_.----------------------------------- 0 <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity- --------------------------gals. <br /> Privy: Distance from nearest well-------------------------- ,,"__ ..-----._Distance from nearest building---.-------------------------------------- <br /> ❑ V3Distance to nearest lot line.------ �------------------------ -----------------------------------------•----------------•--------•--------------------• ------------ <br /> v <br /> Remodeling and/or repairing (describe):--------------•---------------------- ---------------------------------------•-------- <br /> --------------------------- ----•----------------•------------------------- ... <br /> - ------------------------------- •------------------ -------------------------•----------- <br /> . .. <br /> -------------•-------- ,.. <br /> ., -- <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 /> ordiiaes, Sta a laws, and rules and regulations of the San Joaquin Local-,Health District. <br /> (Sig -•- :.f1- max 1/- - [t: __ :* -- -------------------------------------------------•-•-------------(Owner and/or Contractor) <br /> -------------------- -----------(Title)-----------------•-------------- ---- ----------------- <br /> {PIQ , showing size of lot, location of system"in`relation to wells, buildings, etc., can be placed on reverse side), <br /> '� 4 <br /> "`•- -DEPARTMENT USE ONLY <br /> APPLICATION ACCP-PrTED BY------ N----- ------- ---- ��-------- ---------------------------------------- DATE------- Q a- •-`!` - -.a. <br /> s ---------i_ :- ----------------- DATE_----------- <br /> REVIEWED BY_.. ------------------------------ <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------- ----------------------_-- DATE------------------------------------------------------------- <br /> r< Alterations and/or recommendations:--------------------------------------------------------------___--------.--------.....-------------------------------------------------------------------- <br /> ---------------------- <br /> -- - <br /> ----------- ----------------------- ----------------•------------.- <br /> -- --------------------•----------•---------•---------------------- -• •-- <br /> -----------•------ - -•------------ - ----------•------------------- <br /> FINAL INSPECTION BY:------- - !1-- -- 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 /> E5 9 REVISED B-59 2M 5-62 ATLAS <br />