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FOR OFFICE USE: <br />---- ---------------- ------- -------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. ..._ .�r~ ..... <br />------------ ---------------------- ----------- Duplicate) <br /> (Complete in Du <br /> { P P ) 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 st + work herein described. <br /> This application is made in compliance with County Ordinance No. 549. _ � DOS`-I q,0- ✓o f <br /> JOB ADDRESS AND LOCATION-- . r, ir��.... �._._ w.. �,1�' f <br /> r <br /> Owners Name----------------- lrvI----------- <br /> --------------------- --..._ Phone <br /> Address.......-••--•......•-•--. ._.1 .. - Sf --------- <br /> Contractor's Name...-./fir___-—-------------------------------------------------------------------------------------------------------_---------- Phone................................... <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ID Trailer Court J4'Motel ❑ Other ❑ <br /> Number of living units: ________ Number of bedrooms ________ Number of baths -------- Lot size --_-------------- <br /> Water Supply: Public system ❑ Community system ❑ Private ® Depth To Water Table .7 q_ ft. <br /> Character of soil to a depth of 3 feet: Sand []. Gravel ❑ Sandy Loam ❑ Clay Loam R Clay ❑ Adobe❑ Hardpan.® <br /> Previous Application Made: [if yes,date--------------------f No o New Construction: Yes ® No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material________-__-__-_______________-__._._______----- <br /> [❑ . No. of compartments---------------------_._Size---------------_-.------------Liquid depth.-------•--------------•-Capacity-----_------------_- <br /> Disposal Field: Distance from nearest wellJtP__'___ Distance from foundation._fid_"..rf:.._.Distance to nearest lot line._S11....... Q , <br /> Number of lines----e�----------------- -- - Length of each line- — 7P-------------Width of trench---/�------------...--.-.-____-- k� <br /> Type of filter mate Depth of filter material___?~_____.____Total length__'1 _�_____________________.... f <br /> Q <br /> 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 to nearest lot line--------------------------------------- ---------------------••-----------------------••-------•-------•------------------•------ <br /> Remodeling and/or repairing (describe):----- --- r`------- ------ � <br /> .-----•-------•--------------------------------------•--------------••----------------•- -------------------------------- ------------------------------------------------------------------­------------------ <br /> -------------------------W-------- <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 an4reaflons of the San Joaquin Local Health District. <br /> (Signed) �_�e .-------- --- --------------- ---------------------------------- (Owner and/or Contractor) <br /> BY: --------_-------------------•---(Ti+le] <br /> (Plot plan, showing size of lot, ocation of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ ---------- DATE----- __LF_-_ ,.?---------------------------------- <br /> REVIEWED <br /> _____________ ._REVIEWED BY------------------------------------------------------ ----------------------------------------------------------------..._.. DATE--------------------------------------------......... <br /> BUILDINGPERMIT ISSUED----------------------------•---------...----------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations--------------------------- ----------------------_-•--------------------•-----••------------- --••---------••---••-------•-•-•--••----.......-••----- <br /> - - --• ----------' ... --------------------------­--- --------------------------------- <br /> ----------------------------- -, ' <br /> - <br /> ---------------------------------------- -•-••----- --------•-----••------------ --•--•-------•------------- ----- - <br /> v'= '-'G-13----------------------- ---- <br /> FINALINSPECTION BY----------------------------------------------------------------- Date--------------.------------------- ----------------------------------- ...... <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 ti Manteca,California Tracy,California <br /> h <br /> ES 9 REVISED 9-59 2M 5-62 ATLAS <br />