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F R OFFI E SE, f, <br /> �' .-- - ----- <br /> APPLICATION FOR SANITATION PERMIT Permit No. ...�Ian-._..... <br /> ------- ----------------------------+---------•----- (Complete in Duplicate) <br /> . Data Issued --.V/.21.�i <br /> --- -----------._.__----------------------- <br /> ___ _ ____ This Permit Expires 1 Year From Date Issued f�'3w 33 _og <br /> 4,5/f f,J} <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constct and install t e wor erein e crbedd.. <br /> This application is made.in compliance with County Ordinance No. 549. <br /> ` �� �.JOB-ADDRESS A I x= �.� - � / <br /> Owner's Name------- - -------- --------------•-•---------------------------------------------------- Phone.----------••----•--................ <br /> Address ................ - ---- --------- <br /> ---------------------------- <br /> ------ <br /> ...... <br /> ---------------- <br /> •-------------- <br /> ------- <br /> ..... <br /> --... <br /> Contractor's Name-----•-------_-- <br /> ------ Phone--------_-_------------------•- <br /> Installation will serve: �Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ otel ❑ Other ❑ <br /> Number of living units: . __ _ Number of bedrooms d?_- Number of baths __!__ Lot size <br /> 4 Water Supply: Public'system ❑ Community system ❑ Private Depth to Weter Table� _ ft. {� <br /> Character of soil to a depth of 3 feet: Sand El Gravel El Sandy Loam ❑ Clay Loam [I Clay Adobe❑ Hardpan ❑ N <br /> Previous Application Made: (If yes,dote--------------- ------I No ❑ New Construction: Yes ❑ No [Lg-'rHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: o <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 '5 <br /> I ank: Distance from nearest well____•..---_______Distance from foundation--------------------Material................................................. <br /> No. of compartments--------------------------Size--------------------------------Liquid de th--------.._-.-------------Capacity ; <br /> Disposal ld: Distance from nearest well- 0. Distance from foundation___, _(...Distance to nearest lot line_.._ <br /> Number of lines_______.... .____ Length of each line------------3-Q.......Width of trench_____.?-.I/................... <br /> - -------.Total length----------- ----------..-�? <br /> Type of filter materia... <br /> -:Depth of filter materiaL:. _ <br /> Seepage it: Distance to nearest well_/�_r_._..--Distanc. m fo dation./O.--...._ is an�p to nearest lot line_. <br /> Number of pits.... Lining material_ .Size. Diameter._ _. ------------Depth----c -?_-_.......-_._.... <br /> Cesspool: Distance from nearest well____-------------Distance from foundation-------------------.Lining material..__________----•--_________.__...--- . <br /> ❑ Size: Diameter-------------------------------------.Depth------------------------------------ - ------Liquid Capacity------•----•---------------gals. I' <br /> Privy: Distance from nearest well _____________---------------------------____----Distance from nearest building-__--_-________------------_____----___._ <br /> ❑ Distance to nearest lot line--.-------------------------------------------- ------------•-----•---------------•-----••--------------•--•--------•---•--•------------•--- <br /> Remodelingand/or repairing (describe);---------------------------------------------------------------------------------------...---------------------------------------------------------- <br /> ---.....__--��-. <br /> r i <br /> .._.. --•----------•------------- <br /> r <br /> I hereby certify that I have prepared this applic nd that the work will be done in accordance with Sen Joaquin County <br /> ordinances, State laws, and rules and regula+ions-o S Jpaq n Local Ith Dist 'ct. <br /> (Signed) ------- ----------------• ner end/or Contractor) <br /> l gY= ... -----•---------------------- ---=•-- -----------------j-----------(Title)--------- --------- --•---- .... -------- <br /> By:--- <br /> (Plot <br /> ------ <br /> (Phot plan, showing size~of of, locat' of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> 00 <br /> APPLICATION ACCEPTED 6 ---------------------- DATE.... ----/ ---- - --:--------------- <br /> tREVIEWED BY.-. = -•-•------•------------------ DATE-------•------------------------------------------------- <br /> BUILDING PERMIT. ISSUEDF - = A ----------------------. ------------- DATE....--------------------------------------------------------- . <br /> Alterations and/or recomm t ate ns __- .._-. ---- <br /> t -............... <br /> =: <br /> i <br /> -. 1 <br /> ----------_........__________________________4_______.,._____.-______-._._-._.____..________...._______.__._..._____._....____.-_____..._________-__..........._.______.__..____.__._.-____._____....._..................__. <br /> IN, <br /> ----------------------------_--------------------________________________ ..._-----------------_ _________________________________..................................._...................................._......_........ <br /> Date . ................... <br /> FINAL WSPECTION BY:__:_�.... ..., . -------- _ �`� - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South Amerlcan Street 300 West Oak Strout 124 Sycamore Street 205 west 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> tr 9 REVISED 8-59 OIA 5-61 ATLAR <br />