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FOR OFFICE USE: <br /> p i_Z_ <br />--------------------------------------------------------- `"� f <br />--------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..1.. 0..... <br />--------------------------------------------------------- (Complete in Duplicate) <br /> ------------------------- This Permit Expires 1 Year From Date Issued Date Issued .... .......... <br /> Application is hereby made to the San Joaquin Local Health`.District for a permit to construct a d install the work herein descrbed. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESSYANCATIONtd 4 tw •m ----.......-•-------••----........Owner's Name �2!.•�i7iL�t.. <br /> ...--- -----•- --------- ------------------------------------------------------------ ................. Phone.................................... <br /> Address .._1....f . ------. <br /> Contractor's Name.-- -rx'.................................................................................................................... Phone................................... <br /> Installation will serve: Residence k Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of living units: J.... Number of bedrooms 2---- Number of baths .An.. Lot size .......tov.jf/._rTt................................ <br /> Water Supply: Public system ❑ Community system ❑ Private RJ Depth to Water Tableft. <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 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 well4 ........Distan o fro foundation..A?..........Material.._!� ...................... <br /> No. of compartments.__X..................Size_ _._ 't__s ._,_..Liquid depth_....------_.-----__-_Capacity. ........ <br /> _.. <br /> Disposal Field: Distance from nearest well J"'_____ _Distance from foundation/B'_..........Distance to nearest lot line.......... <br /> (� Number of lines_...____ Length of each line___..r_0................Width of trench....¢, ....................... <br /> Type of filter materia •.Depth of'fijter material...ff--------------Total length--Y6............................. <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 /> Remodelingand/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) P­ /,�'t'�t. (,.------ r"-----------------------------------------------------------(Owner and/or Contractor) <br /> By:...................................................................................................................................(riitle)----------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> Ile FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- -- - ------- - -- ----------------- ............................................... DATE---- 2 ------•------------------------ <br /> REVIEWEDBY................................................................-------------------------------------------------........... DATE........................................................... <br /> BUILDINGPERMIT ISSUED..............................................................-..................................... DATE------------------------- <br /> •----------------------------•----- <br /> Alterationsand/or recommendations----------------------------------------- -------------•-•-•-----------------------------•-----....-•----------...........-----•---•-••---..:.._...-•-••-•----- <br /> ---•--•---•------•-----•---•-----------------------•--•-------------------------------------------------------•----------•---------•--•------•--------=--------------------•----•----•-----------------------•-----•--•------- <br /> ---------------------------•---------------------y---- ------------....--------------------------- ........ ------------------•------------------------------ .................................................... <br /> FINAL INSPECTION BY:....r '_........_-. <br /> Date .............................................. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Strout 300 Wast Oak Street 124 Sycamore Strout 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED B-59 2M 5-61 ATLAS <br />