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FOR OFFIC U <br />------ ------------ ------- --- - -------------- ---- <br /> APPLICATION FOR SANITATION PERMIT Permit No. ......�..... <br /> -------------------------------------------------- (Complete in Duplicate) zr <br /> ________________ l This Permit Expires 1 Year From Date_Iss_ued <br /> Date Issued :_..__....Tl.....__ <br /> 77-77 —o--L3 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work berein described. <br /> This application is made in compliant_a with County-Ordinance No. <br /> 4 J-{OB ADDRESS A_N9 <br /> LOCATION-_- <br /> .�._�_.-.. <br /> rt <br /> ------------ <br /> Owners Name_____Address--- ¢-- -- --- P <br /> Contractor's Name--- -0....... .. .1 .. -..................... <br /> Installation will serve: Residence partment House E] .-Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> MJ ka, of livinn I,nj�c• , __fJl,mluarr{.I�/�iArsrtLc . ��mlzftr,sz# <br /> .�f <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. <br /> arac er or son to a dep1fi o� j of. -Sana: propel L3 Panay i_oair► �ti foam U %.ray L1 nuvPe-Lj "crap n LJI U <br /> Previous Application Made: (If yes dote___-`--------- ----I No ew Construction:_ Yes No ❑ FFtA/VA: Yes ❑ o ❑" <br /> TYPE=-OF-INSTAL-LATION-AND'SPECIFICATIOii�-7 _­�"' <br /> (No septic tank or cesspool permitted if public sewer 'is available within`200.feet;) -I <br /> p = " nce front nearesf•w h._- _i(�_..Dis�ance rom found�tron__��.__..__.Materiai__._�-�.. <br /> Septic Tank: •'� Dista J <br /> ro <br /> Noof compartments-...-' Size f Ca eci <br /> t P � - -----•- - -... WO-5- <br /> �x,---Liquid dap#h_.. -- -•- •-- P tY---�i� t / /Disposal 1=i ld: Distance from nearest well,Ii_C. ._Distance foundation-_,!._- TDistance to nearest lot line.____�.__c <br /> Number of lines # ` "` Len th of each lineaZr:.�__W".Width of trench_____, <br /> # <br /> Type of filter materraz_,— c. .be th of filter materia <br /> L.� �' Total len th___/ ..�_.__. .._:__`." <br /> 1 YP r P g <br /> _--- g <br /> Seepage Pit: Distance to nearest well __ <br /> ........ -Distance from foundation <br /> ......:.............Distance to nearest lot line____-___:._.T~`.' <br /> ❑ Number of pits------- _ Lining rfiaterial----------------------Size: Diameter........................Depth-------------------------- <br /> Cesspool: Distance from,.nearest well _------------Distance'from�founda#ion---_________________Lining material........................... <br /> --------- <br /> _ i <br /> ❑ Size: Diameter--• - •;.r,...Depth--------- Z_-2`----' `--- ------Liquid Capacity......................... gal <br /> _ t <br /> Privy: Distance'from neares`t well__________________€__--y_- _.---�_------ Distance from nearest building.w__;._ ___;____________.________;__----;- ? <br /> Distancefo nearest lot line------------------------- -- ----- ----- ------------------•--.....-------•--------.:.-----•--•-----•--•-----------•-------------------- <br /> Remodeling and/or repairing (describe):- ---•-------------_-----------•-•-----------------••------ ------------------------------------------------------------•....... <br /> -- --------------•-------------••---•-------------------------- -----------------------------------• .......-•---•--•- = ------••--------------------------- <br /> i <br /> I <br /> I hereby certify that I h ve prepared this {application and that the work will be don in accordance with San Joaquin Countykzv <br /> ordinances, State la s, nd les and re ulation s of the Sa Joaquin Local ea{th Di. Fit.(Signed). - -- ---- l� ' - ------ � - -- - antractor] <br /> Br•••--........_•---------------- ---------------------.-, _,� _-_----------------- rA--- ------ -�-•drtl - �' { , . <br /> (Plot plan, showing size of lot, location of system.in relati ' o wells, buildings, etc a placed on reverse side). 4 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- } "� -------- -- ---------------------------------------- DATE---------VZZII-------�'-------------_--` <br /> REVIEWEDBY------------------------------------ '----------------------------------------------------------------------------------- DATE.-------••--•-------._._..------_ ------- <br /> BUILDING <br /> . <br /> r <br /> BUILDING PERMIT ISSUED - DATE ---------------- <br /> Alterations and/-or recommendations:_-•--•a --- -- --�"–~---�-- -�.---- <br /> i . ._ <br /> z <br /> l ------ -- --••---•--------------- <br /> f Date I _ v <br /> FINAL INSPECTION BY:_ «--------------•------- j l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Sireet 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E$ 9 REVISED B-59 MM 5-61 ATLAS <br />