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FOR OFFICE USE: <br /> ----------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br />------------ -•-------------- ----------- --------------- (Complete in Duplicate) <br /> 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 construct and install thework erepn do crbed. <br /> This application is made in compliance with County Ordinance No. 549: x-73 <br /> JOB ADDRESS AND LOCATION.-/ n---Ai0_ ..............------------- f l-- 'f�`. __�� LJ�•-._--- _ .. .�� `. <br /> Owner's Name -------------------- ----------------- ------------------------- Phone 1, _ .. <br /> Address------------ = 2 4g, •4/0--la........--- --•--------------------....................................................... <br /> Contractor's Name----------------- Phone <br /> Installation will serve: Residence g3"'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of living units: _/__ Number of bedrooms -- Number of baths __/. Lot size _, " .,t�.,l '. .......... <br /> Water Supply: Public system [Community system ❑ private ❑ Depth to Water Table _004. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2"Hardpan ❑ <br /> Previous Application Made: (If yes,date-----._.._. --------I No New Construction: Yes g3�'No ❑ FHA/VA: Yes ❑ No 23— <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet:) <br /> ---------.Mat ial .. �._..... <br /> Sceptic T nk: Distance from nearest well----- _.--_. Distan /from foundation._ r <br /> [� No. of compartments r�________.._____Size �f,��______-__.Liquid depth_.. -.f __.___:_Capacity..t l�.r.�...... <br /> Disposal Field: Distance from nearest well_________________Distance from foundati ---/0_........Distance to nearest lot lina_ttd�__ .._:... O <br /> Number of lines...... __ _____ ______ _Length of each line.... Width of trench--,2- <br /> / _ -------- <br /> ____ - b� <br /> of filter materia p ppfj ---- g _f <br /> Depth of filter material____�A_.____.___.Tota! len th____ __ ___________-- <br /> Type <br /> Seepage Pit: Distance to nearest well-----__•`--------Distance f m fa dation•--��{.._..D's rice to nearest lot line___.... <br /> Number of pits___.___/________-__Lining material_ 4PL�_.Size: Diameter��C____--Dept h__ ................... <br /> Cesspool: Distance from nearest well------------------Distance from foundation---.---------------.Lining material------------------------------------- <br /> 13 Size: Diameter-------------------------i-----------.Depth------------- --------------------------------------Liquid Capacity............................gals. <br /> Privy: Distance from nearest well----------------------------------------- _______Distance from nearest building______.________-------.------_______--.... <br /> ❑ Distance to nearest lot line------------------------------------ -------- ----------------------------------- - -------- -------------------------------------------- <br /> y <br /> Remodeling and/or repairing (describe)------------ --------------- ...4,111;114�--• ---•------•----•-----------------.......... <br /> -----------------------------------------------........................----------------------------------------------------------------------------------------------------------------..............­------------------- <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 th San Joaquin Local Health District. <br /> (Signed)------------------------------ �.-.----� - --ion <br /> -----._... ----------.------------------( or Contractor <br /> Li/�'� -•--- Title------ <br /> (Plot plan, showing size of lot, location of system in r to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPAR.MENT USE ONLY <br /> APPLICATION ACCEPTED BY------- --- - --- ---- ------A-------• ---_------•---------------- DATE----- ----- <br /> REVIEWED <br /> ---REVIEWED BY-----------------•------------ •-•--------- --- ------------------------------------------•-----------•---------------- DATE------ -----------------•---------------------------------- <br /> BUILDINGPERMIT ISSUED-------------------------- - ----------------------------------------------------------------------- DATE-------------------------- ----------------------------- <br /> Alterations and/or r com enct tions---------------- .----------- --••.•.---.--------- •- <br /> ------------------ <br /> lo ,--�- - 6- _ - ..��1_. a -----•----------- <br /> FINAL INSPECTION BY:....- ... Date------- 1 --------------------- <br /> y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wemt Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED B-59 ZM 5-61 ATLAS <br />