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3 ---------------- <br /> ------------ <br /> --- -- --- <br /> _________________________________ APPLICATION FOR SANITATION PERMIT Permit No. <br /> -------------------------------------------------- (Complete in Duplicate) Date Issued .... 3 6 L <br />--------------------------------------------- .......... This Permit Expires 1 Year From Date Issued ..�.. "" <br /> OQ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the war 19�herain described. <br /> This application is made in compliance„with County Ordinance No. 549. _ r+__ <br /> JOB ADDRESS AND LOCATION.. -- :` ....... 9.a.... <br /> .... <br /> ,�,�,r.�'�' <br /> Owner's Name-- .....--- -Qr.......................•------•-------.....-•--•------------- Phone.xJ"'-.$. ..1a Zr <br /> Address.............. �.. X / <br /> { j<r........ .ravr-r ...................... ................ <br /> Contractor's Name.. .......... %.... Phone................................... <br /> Installation will serve: Residence ff p rre11 House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ._`7. Number of bedrooms ...��/ Number of baths ...'j.-Lot size .....-. .................... <br /> Water Supply: Public system ❑ Community system ❑ Private [,2; Depth to Water Table .tr-?rft. <br /> Character of soil to a depth of 3 feet:` Sand❑ Gravel ❑ Sandy Loam S Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (if yes,date....................} ',No a New Construction: Yes J3 No ❑ FHA/VA: Yes ❑ No Eff <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ' <br /> (No septic tank or cesspool permitted if public sb'wer-is available within 200 feet.) <br /> SAptic Tank: Distance from nearest well... Distance from foundation...../......... ........................ <br /> 0 No. of compartments.._.____._? .........._Size_./Tr-.K...KXV-iquid depth..........3/e�.......Capacity.,l.. .-."....Yv. <br /> Disposal Field: Distance from nearest well____ ^Ct._.Distance from foundation....,.R..w.....Distance to nearest lot line.... ... !. <br /> Number of lines.....___---.•__ -_ Length of each line.......... .....Width of trench.......... ......_ _ <br /> Type of filter material-. 0 _ .Depth of filter material...._ .. ”-_.Total length...........2— S,............... <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- <br /> El Number of pits----------------------Lining material................ ......Size: Diameter_.................._..Depth__--_*...._._...._.._...._._._. <br /> Cesspool: Distance from nearest well.................Distance from foundation.................[Lining material.................................... . <br /> ❑ Depth----------------- ..A-Liquid uid Ca aci <br /> Size: Diameter. `._..........-.... 9 p ty.........f.. gels. <br /> Privy: a `� Distance,from nearest well..__...... ,.._r'__ t_`_`._____-.____Distance from n crest buildin <br /> g.......................................... <br /> ❑ Distance fb nearest lot line......................... 1-. �- <br /> { .......-----•-•--_... I.... ................. <br /> Remodelingand/or repairing (describe')-------•--••--- -------------A....------...---•---•-•----•-•---....I...........�... ......................................................-•--•• <br /> ------------------•----•---------•--••••-----••-----•.............................................................--•------.....................>...........................................•--................... <br /> `% -1 1 <br /> .........................................................................•-•'--•--....-••••-=-•-•-----••-------------....--------•----•----•-------•------...-----•--•--.......-••----•---.....-- <br /> �� <br /> .....................•----------•-......-----••------------- I <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 Disfrict.1 <br /> (Signed) .. .._ ..-------•--- -- ----------------------------------------------------------------------------------•-------.(Owner and/or Contractor) <br /> ------------------.............................................................................................................. .(Title)-------------------I_...__.------------------ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side), <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- , ----------------------------------------------------- DATE.......... <br /> •• 4 ' <br /> REVIEWEDBY----------------------------------------------------------------------- <br /> •------- <br /> •---------------------------------------------- DATE........................................... <br /> PERMITISSUED---------------------------------------------------•-------------------------------------------------- DATE------.-....----•----------------------._...-------- ...... <br /> Alterations and/or recommendations:--------•-••--•-•--- ----------------------•-------•----------••-----------------------------•--........................................------•------------- <br /> -----•---------------------•-----•-•----------••-------•-------.... ------........---------------------------------------------------------------------------.--------------------------------------------------- <br /> --------------------------------------------- <br /> --------------- --. ---------•------- ------------- •----------.-------------------•------------- <br /> - <br /> FINAL INSPECTION BY:..... Dete.- z r � <br /> SAN JOAQUIN LOCAL HEALTH'DISTRICT <br /> 130 South American Street 300 West oak Street 124 Sycamore Street 205 wort 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> 'ISED 9-69 ZM 6-61 ATLAS <br />