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FOR OFFI E USE: <br /> I,�, ICATION FOR SANITATION PERMIT— Permit No. <br /> ------ -------------------------------------------------- (Complete in Duplicate) <br /> Date Issued .�17-A�. <br /> ------------------------------------ __---------------- TIxis 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 the work herein described. <br /> This application is made in compliance with County Ordinance No. <br /> 5 <br /> / pW <br /> JOB ADDRESS AND C ION.... ..(lTfr•_______ ____ _ __--- ------------ ----------------------- <br /> Owner's Name.. = <br /> Phone--------------•------------------- <br /> ----------------------------------------- ------- <br /> Address------ - - -- ---------•------• -•---------------------- ------ ------------------- <br /> ---•-••-----------------•-------------------....-----------------...--------...----•---•----------••---- <br /> Contractor's Name------------- Phone................................... <br /> ------ <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court a__MZtel ❑ Other <br /> Number of living units: Number of bedrooms --le- Number of baths -_/--- Lot size ------------------------------- <br /> Ir <br /> Water Supply: Public system ❑ Community system'❑ Private Depth To Water Table __ t. <br /> t Character of soil +o a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [3 Adobe[��ardpan C3 <br /> Previous Application Made: (If yesfdate--------------------) No [21-'New Construction: Yes Io ❑ FHANA: Yes ❑ No 24-- <br /> r <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if pubkic sewer is available within 200 feet.) <br /> t <br /> Septic Tank: Distance from•nearest we __f�49 <br /> _Distance//fom foundation__-'� __---.Mate ial--- -- `:<<r!-'--"p`-. <br /> ----.-.-.-.-.- <br /> & - / Capacity G --- --- /No. of com artmen _____________ � Liquid depth <br /> Disposal Field: Distance from nearest well../ from foundation-------'........Distance to nearest lotline..s . .�.... <br /> Number of line ---------- ---�---- -Length of each line------ �---- ! -----Width of trench.-- `-•--------------- <br /> ------ <br /> Type of filter material. � Depth of filter material_-.1�._.__......Total length...._��____________________________ <br /> I D st f�e to nearest I t linej..t - ------ <br /> Seepage Pit: Distance to nearest well from foundation...r.____._.. <br /> cgs' Number of pits---_`-------------Lining material__. --Size: Diameter_ _._..___.Depth ------------------ <br /> 1 Cesspool: Distance from inearest well-----------------Distance from foundation--------------------Lining material--------------_-.-_-----__---__-_- <br /> ' ❑ Size: Diamete ----------•---- -------------------Depth----------------------------------------------------Liquid Capacity---------_----- <br /> ------------gals. <br /> Privy: Distance fromnearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> I <br /> Distance,to nesrest lot <br /> I line------------- ------------ ---------------------•--------•----------- <br /> ----------------------- <br /> ---------------- <br /> Remodeling and or repairing Ides)vibe) 1"' <br /> I --------------------- - ---•-----••--- ------------•-------------------------- ---------------------------------------•-•------•-----------•----------------•----- <br /> -------------------- ------ <br /> ------------------------------ - ---•- <br /> --------•---•--------- -------------.------- -----• ---------------------•--------•-•---------------•------- ---------------------•--•-------------------...-------------- <br /> here6y 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 pies and regulations of +he San Joaquin Local Health District. <br /> l <br /> -------------------------------- - -(EhmmmsiamdLor C- <br /> ontractor) <br /> -------------5i reed :_----------------- -BY <br /> (Plot <br /> plan, showing size of lot, location of system in ation to wells, buildings, etc., can be placed on reverse side). <br /> rY6R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----F------------ --- -- -------------------------------------- DATE----------�-- ----- -- --- ------- <br /> REVIEWED BY---------•-------------------•--�--- -----•------ ------------ ---•--- ------------------------------------ •-------------- DATE------------- =---------------------------------------------- <br /> -------....---------••-------------- <br /> BUILDING PERMIT <br /> ... �. /SemISSUED-------_• <br /> - <br /> ---------------- -- - <br /> -------------------------------------- DATE------------------------------------------ <br /> -.------------------ <br /> --------------- <br /> Alterations and/or recommen a I :.--- -- - - . ------------ <br /> ­-------------- <br /> .---------- <br /> . --- -- --------------------------------------I ---- -- ---•------------ ------------------. ------------ <br /> 1 -----------------------•----- -------------------------------------- <br /> ----------------- ..................... ------------- <br /> I <br /> FINAL INSPECTION BY:.----. ..._........ r ...a Date----- �� ----------_---------------- <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wast Oak Srreet 124 Sycamore Street 305 West 9Th Street <br /> Stockton,California lodir California Manteca,California Tracy,California <br /> ES 9 REVISED B-59 2M 5-62 ATLAS , <br />