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FOR OFFICE USE: <br /> --------------- ------------------------------------- r f <br /> ---------------------------------------.----------------- APPLICATION FOR SANITATION PERMIT Permit No. . . ....... . <br /> - --------------------- -- ---------------------------- (Complete in Duplicate) <br /> ------------------- This Permit Expires 1 Year From Date Issued Date Issued _6.0 ...l�_ <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 County Ordinance No. 549. Sj — 330—c" <br /> :- <br /> JOB ADDRESS AND�LOCAT ON_.- es.<t ._-Yt. e4�.- .....---••-........ -• - <br /> Owner's Name------- - I ----- Phone-----------•............... <br /> Address------------------------------- -- --- ... .... . - <br /> Contractor's Name... ------ ----------------11------I------ ...­........................... --------- Phone---------------------------------- <br /> Installation will serve: Residence,x Apartment House E] Commercial E] Trailer <br /> ��//Court ❑ Motel C] Other [3Number of living units: ._,[..__ Number of bedrooms _� Number of baths .__'2-'(0f size ------_________________ <br /> Water Supply: Public system [] Community system ❑ Private Depth To Water Table Xoft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Claytoamtw' Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (if yes,date--------------------) Noy <br /> o t� New Construction: Yes [3 No _ FHA/VA: Yes El No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: //�\ <br /> (No septic tank or cesspool permitted if public sewer is available within 2DO feet.) <br /> Se tic Tank: r Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- <br /> compartments <br /> --______-________-________________-_________-__. <br /> No. of compart ments------ -•------•-------Size................................Liquid depth---•--- ----- ------Capacity----•---- •. ..-•"r <br /> TDis 'osal Field: Distance from nearest well__:��__-_Distance from foundation----o!_d7-------Distance to nearest lot lin <br /> c Number of lines_-----�....___ --------- <br /> --__ Length of each line------/Q-_Q___-__ Width of trench----�._�_________________ <br /> Type of filter material.5I �,,.Depth of filter material____� ____To#al length_____ ----------------------- <br /> Seepage <br /> _ ._Seepage Pit: Distance to nearest well----------------------Distance from foundation................___.Distance to nearest lot line................. i <br /> ❑ Number of pits._-------------------Lining material-----------------------Size: Diameter.......................Depth................................. N' <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---.------------. _.Lining material__--______--_________________________ <br /> Size: Diameter---I----------- -De th---------------------------- ----Li Liquid Capacity..-, <br /> ❑ --------------------- P -------------------- q --_....-•-•-:•-••------_gals. 1_, r"` <br /> ..... ..a -�� r.. -Fes- - -. , <br /> Privy: Distance from nearest well____________________________________---_-_-___-_Distance from nearest building------------------------------------------ <br /> Distance <br /> ______-______________-_-_-___--____-_ ---Distance to nearst lot line------------------------------------------------------------------------------------------------------•-------------------------------------- { <br /> Remodelingand/or repairing (describe)------------------------------------ --------------------------------------------------------------------------------------------•------------------------ r,•��: <br /> ----------------•---------------_-----_---------•-----.-----------------------•-------•------------------------------------------ <br /> i J <br /> hereby certify that 1 have prepared this application and that the work.will be done in accordance with San Joaquin County <br /> ordinances, State la . , and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)----_ ---- -- ----------------------------------------------- (Owner end/or Contractor) <br /> By:........ ---...._I---••----•----------•-•-•---------------------------------------------------------------------------------------(Title)----------------------------------------.---. .... ----------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------- ---------------------------------------------------------------------------------------- DATE--------------------------------- -------------- <br /> REVIEWED BY = DATEof----- <br /> BUILDING PERMIT ISSUED-------------------------------------------- ---- - • - - --------------•-------------------- DATE--------- { 6- ----------------- <br /> Alterations and/or recommendations----------------------- ---- ---;; - - - -- --------------------------•-----------•-•-•------------•-------•----------•--------------------------- <br /> -•------------------------------------------------•-•-----.---�---------------- . ----------- ---------------------•--- ---------------------------------------------------------------------------------------------- <br /> •-•--•----I--------------------------------------...--..--•---=------------------------------------•--------------------------•--•--••••-•----•----•-----•------•------------•------------------------•-•--••---••-----.------ <br /> I <br /> FINAL INSPECTION BY:........ f---- --- Date---------------------la----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California *anfeca,California Tracy,California <br /> ES 9 REVISED B-59 2M 5-62 ATLAS <br />