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1-UKUl-1-K-t llbt: <br />------------------ ---------- --------------------------- <br /> -------1--- <br /> ----------------------- ---------------- ------------ --------- --------------- APPLICATION FOR SANITATION PERMIT Permit No. ..1..�`�'.�_.. <br />------------ -•------------------------- ---------------- (Complete in Duplicate) <br /> ------------------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued ...................... <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 Co my Ordinance No. 549. <br /> JOB ADDRESS AN OCATION-- '- ----------------- .. GrrPi. <br /> -----_ <br /> Owner's Nam Phone-- <br /> Address----- . ........ .. .. •a <br /> Contractor's Name-------!--...--� =-- -•- ....---=•--------- .................. ----------------------•-......................................... Phone................................... <br /> Installation will serve: Residence partment House ❑ / _Commercial E] Trailer .-Court F] Motel ❑ Other ❑ <br /> Number of living"units: _�Number'of bedrooms __Number of baths __le"Cot size ----- r-- -. - ,--- <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table <br /> Character of soil to a depth of 3 feet:4,Sand ❑:Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ <br /> Previous Application Made: (if yes,date�.___.____----_-) No (K New Construction: Yes Ibg No ❑ FHA/VA: Yes ❑ No r <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: z <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tan Distance from nearest well_________________Distance from foundation_______......_..-__.Material•-_________�._................................. <br /> EVII <br /> No. of compartments----•------------------ `1ze----------•-•-•-•-----------....Liquid depth-------------•------------Capacity-..--...------------•-- <br /> Disposal Field:, Distance from nearest well______ -.._Distance from foundation---VP.........Distance to nearest lot ling... ..... <br /> Number of lines________________ __ Length of each.line______ ®__ Width of trench........ <br /> ..__.___.-- <br /> ! f f ..)) <br /> Type of filter material.vl.7 Depth of.filter material..T_:._"�__Total length-------d-.C�...........:........... <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation----------------—Distance to nearest lot line................. <br /> ❑ Number of pits----------------------Lining material-----------.------------Size: <br /> f \b•l meter__-_-..---------------:Depth-----------.------.-----•--.: <br /> Distance4om-nearest well_________________Distance from foundatiolr"Cesspool Nk -------------LInngmaterial <br /> material.______......_.________..•.•..___._._ <br /> _. <br /> r <br /> ❑ 5rze Diameter_-.-. . ------- ---------------Depth----•-----....-----------------•- --'=-------Liqu-r1 Capacity-----------------------------gals. <br /> --. _— <br /> Privy: Distance from nearest well_______________________________•_--.____- -----Distance from nearest wilding__.._._________..-.•-_-_._.__..,....__...- <br /> ❑ Distance to nearest lot line-----------------------•--------------------•------•----__-_-- <br /> Remodeling and/or repairing (describe):------------- <br /> ` ti " .... <br /> "-A. -!� ---•..................... <br /> ------------------•-----=----- <br /> i <br /> * -- <br /> ---------------------­---- <br /> ----------------------••-•--. :..... <br /> t t x <br /> ' ----------------------------•-•-------- ..... ---------------------------------------_----•---------------•--•------- <br /> I hereby certify that I'have prepared this application and that the'ark will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the -44n Joaquin Local Health District. <br /> {Signedr.._ 'fir. t _ r and/or Contractor) <br /> By----------------- = k_ V .. I <br /> Plot Ian, showing size of lot, location of s sferr in relation to wells, buildings, etc., can beplacedon reverse side). . ' <br /> P 9 Y 9 P <br /> FOR DEPARTMENT USE ONLY .. . <br /> APPLICATION ACCEPTED BY------------------------------------------------ ------------- ---•----------------- DATE------ -••------••-- ------ <br /> REVIEWEDBY-----------I------------ ---------•-•----"---------------------------------- - •--• DATE_._..------.. <br /> BUILDING PERMIT ISSUED------------------------------ ` <br /> -------------- - DATE <br /> and/or recommendations:_--___.______________________ I <br /> --- --------------- -------•- .------ <br /> f <br /> S <br /> I <br /> 'i-------------------------------------- <br /> ............................... ...... . ----------- - --------------------------------------------------------------- --------------- ---------------- ........-------- <br /> FINAL""INSPECTION BY_______ ______________--------- - Date--- ---•-- -------6- ------------------- <br /> A <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 lodl,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 ZM 8-61 ATLAS � <br />