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FOR OFFI E U E: - <br />_-___ _ + __________________________ ___ APPLICATION FOR SANITATION PERMIT Permit No. ....... ........... <br /> ---------- ----------------------------------- (Complete in Duplicate) <br /> Date Issued ____ <br />--------------------­ --------------- ------­­----------- This Permit Expires 1 Year From Date Issued <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 /> 3 <br /> JOB ADDRESS AND OCATION...... ------•---- <br /> Owner's Neme ------ � J-------------------------•------• --•----------------------------•----••-------•------ Phone.................................... <br /> Address----------------1�/ ! <br /> Contractor's Name-------- -- -----r -------------------•----...----------------- ------- ---------------------------------------- Phone.................................. <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' <br /> Number of living units- .-/-- Number of bedrooms ---?_. Number of baths -Z- Lot size .L ,? ___ ----.._-•-_••.----•--------------- <br /> Water Supply: Publics stem ' <br /> y Community system ❑ Private ❑ Depth to Water Table �Q ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: (if yes,date____________________) No OrlNew Construction: Yes ❑ No 2—'FHA/VA: Yes ❑ No P— <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permiffed if public sewer is available within 200 feet.) <br /> S.ptic Tank:,, Distance from nearest well---------------__Distance from foundation.....................Material.................................................. <br /> 1L,u,>4 At if No. of compartments---.----- ----------------Size--------------I ______. _._:___Liquid depth--------------------- Capacity <br /> Disposal Fi91d: Distance from nearest well-------�"-------Distance-from foundation--A©-0........Distance to nearest lot line... ........... <br /> Number of lines._________/_______ _____ ____ __Len th'of each line_____ <br /> L g ti Width of trench_ __....... <br /> Type of filter material_ „l�t� Depth of filter material----- --------------Total length....,`,rte______-_--.--_•-_--•--:_-•__ <br /> Seepage Pit: Distance to nearest well____------__Distance from foundation___/?P._ .___.Distan e to nearest lot line...47 <br /> UR-"* Number of pits__...� <br /> ---- ------- material_ .lr ___Size: Diameter__Iw?&_____---------Depth-A­sJ_!---------1...____. <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-----------------._. -...._.________ <br /> a❑ Size: Diameter--------------------------------------Depth---------------------- •----- ---------------------_Liquid Capacity• ----------------------..._gals. <br /> Privy: Distance from nearest well-----------------------------------_-------_-----Distance from nearest building------------------------------------------ <br /> ElDistance to nearest lot7ine------------------------------------------------------------------------ ......----------------------•----••------------------ ....... <br /> Remodeling and/or repairing (describe):------------4940, <br /> ----- -- ---- } �. ........•-----------------------------------•------------•---------------------•-- <br /> ----------- --------- --•-----------------••------••-•---------------------•------------------------ <br /> ________________________________________y_____________.-.-____.______-____-___________--._..__.___________-__._-------___.______________-___........_____..__----.._-____.___-_____..____..-..___._..._____________--________ <br /> 1 � <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 rules and regulations of the San Joaquin Local Health District. <br /> (Signed).................. r ------ ------------- ------------------------ ---------•-• -----------(�or Contractors <br /> BY: (Title)....... -- -------------- <br /> (Plot plan, showing size of lot, location of,syste relation to wells,.buildings, etc., can be placed an reverse side). <br /> FOR DEPA T ENT USE ONLY <br /> APPLICATION ACCEPTED B ------- -------•------------------------- DATE-------!V/- <br /> REVIEWED BY----------------------------- ---------------- ---------------------------------- -­------------ ----------- ••� <br /> DATE-------•- -•-------- <br /> BUILDING PERMIT ISSUED. ------- DA�---• - <br /> FFerat' ns and/or recommendations:_.__ -- �(Q- _:,- 2 - <br /> ` ---------- ------•-------------••--•--------•-------- <br /> 1 <br /> v At <br /> ----- <br /> _ : t. =�----�-----A-... 0- --------------- <br /> FINAL INSPECTION BY:. -----------------------------------------------------•-•----- Date------- ---------------------------------------- i <br /> Y � <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street. 300 West Oak Street 124 Sycamore Street 205 Wast 9th Street <br /> Stockton,California 4 Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED 8.59 ZM a-61 ATLAS <br /> `Si <br />