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FOR OFFICE USE: ' <br /> -. - --------- 7 )(1 <br /> f 0a'dL.. `� Perm4 No. -••-------- --------- <br /> -`--- APPLICATION FOR SANITATION PERMIT <br /> ---------------- <br /> -- ------ - <br /> `�// ' �---.-/-� __ (Complete in Duplicate) - <br /> /S'' Z = Date Issued ..------ <br /> ----------------------------- This Permit Expires 1 Year From Date Issued _.> <br /> Application is hereby made to the Sari Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance th, &nty Ordinarice•No. 549. <br /> a// O <br /> JOB ADDRESS AND LO ATION__-.__3__$DSI_... ...... .�_---- •--------- <br /> Owner's Name----- _ ••-----------------•-- Phone........__----------_---- <br /> -------------- <br /> Address_-..-....... . <br /> g.a -------- <br /> Contractor's Name.---- . _.. --••-•-•-----•-- -•-•------•----------------_--- Phone--------------------------------- k <br /> Installation will serve: Residence {Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __r-_.. Number of bedrooms 3__-. Number of baths ---.... Lot size __-- .............................:.: <br /> Water Supply: Public system Community system ❑ Private ❑ LDepth to Water Table.p? . ft. <br /> Character of soil to a depth of 3 feet: Send ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe["irdpan ❑ <br /> Previous Application Made: (if yes,date--------------------) No W""New Construction: Yes ga- No ❑ FHA/VA: Yes 21--No �] <br /> 1 <br /> -TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> i <br /> Se tit nki. Distance from nearest weliz2jar-__Distance from foundation-1a-------------Material---_---- ----------------- ................ <br /> p No. of compartments.---• ___-- -------•-Size__••---- y�S'Y- -___Liquid depth_.... •-- --------------Capacity.Disposal Field: Distance from nearest well-! ...Distance from founclation.10_..-_-_.-...Distance to nearest lot line__�3~�........ <br /> ". <br /> Number of ;linesi_____________ ________________Length of each line___-___-_--74-"---------Width of french-.----'z .'.-__-----.....--..__ <br /> Type of filter ------Depth of filter material--19---------------Total length...------- ......__......... <br /> 1Distance from foundation_��--__-•--_-.Distance to nearest lot line-4 .......... <br /> Seepage Pit: Distance to:,nearest well�W74--._ <br /> Number of pits.!._._-.X�---------Lining material-_---- -...Size: Diameter----__317-`...--_.,Depth--------.--1:24 ---------- <br /> I - <br /> Cesspool: �, Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- <br /> ❑ Ei Size: Diameter.1------------------------------•••-Depfh---------------------------------------------------Liquid Capacity------- gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------.-__----_------------- <br /> ❑ 'r Distance to nearest lot line-----------------------•-------------------•--- ----••------------------------ ------- <br /> Remodeling and/or repairing (describe)-------- -------•---------------•---------------•--••----------------=•-------------------•------•----•--- ---------------­-- -------:.-•- <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 /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)-----'---------------- -•-------- ---- ---------- <br /> ----------------------•-• ------------ <br /> ------------••-•----------------•--••-----------------------•---(Owner-and/or Contractorl <br /> By:-!......--------•---------------_-----------------------------------------------------------------••• (Title) <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 /> ------------------- <br /> REVIEWEDBY------------------------------------------------ - ---------------------------------------------------- DATE.. - <br /> BUILDINGPERMIT ISSUED..--------_-- ----- ------------------------•------------------------------------------ DATE-------•----------------------------•--•----------------- <br /> AFFeratf� datons - s r ... .� <br /> �.» :.. <br /> ........... C -•---- --•-------- = ------------------•----•----------- <br /> .:--------•.-•--••---------------------------•---------- <br /> -- ----•---------------- <br /> --------- <br /> --------------------- <br /> ---....------ <br /> .---------------- <br /> ....._ ---------- <br /> Date----- <br /> ---------Date----- -------------------------------•---•--- <br /> E; SAN JOAQUIN LOCAL HEALTH <br /> I � ------------FINAL INSPECTION BY:./ .� DISTRICT <br /> 130 South American Strut 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,Callfornid Lodir California Manteca,California Tracy,California <br /> ES 0 REVISED S-SO 2M 15-61 ATLAS <br />