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FOR OFFICE USE: <br /> - -------------------------------------------- --------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. _. ..1 ••• <br />---------- - ------- --- ------------------------------- (Complete in Duplicate) / <br /> ---------------------.------------------------------------ This Permit Expires 1 Year From Date Issued <br /> Date Issued ___.._��.7..-_�2• <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 /> JOB ADDRESS AND LOCATIO ---.30 _ ----------- ------------_---------------------------....------------------------•-----------------•----- C <br /> Owner's Name ---- ......... ------••----------------------------- -----•---------------- Phone <br /> .3C� d <br /> Address------------------�s}... . -------- r -----------------------------------------------------••-------------------------•------------------------------------------------.............•............... <br /> Contractor's Name------ --------------- -------------------------------....------------•------------------------------------------- Phone................................... <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ f <br /> Number of living units: __/-___ Number of bedrooms __Z-- Number of baths J___ Lot size ......___-•••_---- ------------- <br /> Water Supply: Public system ❑ Community system ❑ Private EEj"b_epth To Water Table_ 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 Efr' New Construction: Yes ff'No ❑ FHA/VA: Yes ❑ No P' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic k: - Distance from ne .. <br /> arest well_________________Distance from foundation___ _____________..Material________________---_-__-____------------._..____- s <br /> �f No. of compartments----------------- Size--------------------------------Liquid depth--------------------------Capacity---_-•--------`.. -. <br /> P <br /> Barest well_______.._ <br /> Distance from foundatiod --_____Distance to nearest lot line_v ..____. <br /> 4::y Number of lines <br /> Dis os Distance from nearest Length of each line--,3 A;-U_--------.Width of trench-----�_k__�__________________ <br /> Type of filter materiaL_.7rgG __._-__Depth of filter material---/K------------Total length......Zs-.!------------------------ 0 <br />'E Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line................. <br /> [] Number of pits----------------------Lining material-----------------------Size: Diameter---.---------------- Depth-_------------------------------- <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material_-__._________-___-____________----_ <br /> ❑ Size: Diameter-_.-:----------------------------------Depth------------------------------ ---------------------Liquid Capacity.---------------------------gals. <br /> Privy: Distance from nearest well---_-------------------------------_-------------Distance from nearest building------------------------------------------ <br /> Distance <br /> ______________-._--__________-.--.------ <br /> Distanceto nearest lot line.- ----------------------------------------------•--------•--•-• ------ •-----•--•----•--------------...-------_------------------------------ <br /> Remodelinand/or repairing describe --- ------------------------------------------•---------------- -----------------------------------.................................... <br /> I ----------------------_----------•------------------- ---------•---------------------------••----•------------ ------------•------------------------------------•-------------------------------------- <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 d r gulations the San Joaquin Local Health District. <br /> (signed)---------------•------ --------•---- •- -- ---------------------------------------.--------------------- -------{Owner and/or Contractor) <br /> By:---------------_------------------------ ------------ ------ -------------------------------------------- ---------------------(Title)-----------------------------------------.------------------------ <br /> (Plot <br /> ....--- ---------- --(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> 1 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----Q .--- .�--s-------------------------------------------------------------- DATE------lZ 4 b ------------------ <br /> REVIEWEDBY---------------------------------- 1 --------------------------------------------•---------------------- DATE-------•-------------------•-------------•----•-----------.. <br /> BUILDINGPERMIT ISSUED..............I------------------------------------------------------------------------------------ DA-TE------------------------------------------------------------ <br /> Alterationsand/or recommendations:--------------- -- ---------------------------- -------• ••----------------------------------------•-•-------•-----•------•---•-••---------------------------- <br /> -------------------------------- --- ---------•----------------------------- ----------------------------------------------------------------------------•----------------- ----••-•--••----------------------•----------•--- <br /> ----- -------------•-----------•------------•---------- -------••--------------•-----------------------------------------..._..--------•--- <br /> i <br /> 7 <br /> FINAL INSPECTION BY:. 1�T` Date------ f/. 1.-- -------- <br /> SAN J UIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wert Oak Street 124 Sycamore Street 205 West 9th Strut <br /> t Stockton,California Lodi,Callfornla Manteca,California Tracy,California <br /> E5 9 REVISED 8-59 2M 5-6z ATLAS <br />