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FOR OFFICE USE: <br /> ------------ ------------------------------------- <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 constru t and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. Ali t�q) r � J <br /> a per, r ~—� <br /> JOB ADDRESS AN CATION_ �_.__c --+�� - t ..._. .... . ... ............. <br /> r <br /> Owner's Name . �/- t f��-c ..- <br /> ....................................... ••..........................•------- one.................................... <br /> Address1.... ...- ----•................ <br /> 6P-. -- <br /> Contractor's Name. C�"=-Li'` ... `. Phone ...... <br /> Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.❑ <br /> Number of living units: _�..... Number of bedrooms I__- Number of baths ___ ... Lot-size .....: -v -- ................... <br /> _ <br /> s <br /> Water Supply: Public system ❑ Community system [I Private M Depth to Water.Table ..,'.__. ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam Clay Loam.❑ Clay ❑ Adobe❑ HardpanCl . <br /> Previous Application Made: (if yes,date-------------------.I 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: Disstahce frorrinearest well_________________Distance from foundation--------------------Material----------------------------------------------- <br /> ❑ No. of compayrtments--------------------------Size-------------------------------Liquid deP.ih---------------------------Capacity........----------..... <br /> Disposal F : Distance from nearest well_Y.5_._----Distance from foundation_____. 2_____----Distance•to nearest lot line....-..::.,. <br /> Number of lines_____________ <br /> --------__�-./� Length of each fine--------- 'Q--�rl-----Width ofarench-------.1 --------------------- <br /> Type of filter material....ei Q—_-Depth of filter material....... 14__-.-----Total length.......Y-116.......... <br /> Seepage Pit: Distance to well----------------------Distance from foundation--------------------Distance.to nearest lot line----------------- <br /> ❑ Number of pits-------------1-------Lining material-----------------------Size- Diameter------------------- _..Depth-------.---_-_---------_---.----. <br /> Cesspool: Distance from nearest well..........::..:.:Distance from foundation--------------------Lining material-------------_____________:_______--� <br /> ❑ Size: Diameter_--.----•------ •---...-•---------Depth---------•---•--•• --------------------Liquid Capacity-------•-•-----------------gal <br /> Privy: Distance'fro"m"nearest well-------------------------------------------------Distance from nearest buildin`g' ._..___________.__--_____.__.__.____. <br /> ❑ Distance-to nearest lot line------ --•-- ....•------------ <br /> - ` <br /> pml�ocrtefiin �/ar repairing (describe)________________ __.__ <br /> ------------•----•------------------•------------------ ..............--•-•-•--•--------------------------------------•---•--------•---------------------------------------•----..---•----••------------------------ <br /> --...-•--••---•.-••--••-•..................•-----------------------------.-----••-•----------•---•--•-------------------- --------------------------•-•-------•--•--------------------•----...--•-------I......_._._._........ <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 tawp, and rules and re ulations oY::� <br /> Joaquin Local Health District. <br /> (Signed) •.-�........... ......... -------------------_.-_._ nd or Contractor <br /> By:.....-----e�_,D-- ------- '-------- ------------------•-(Title)-------------------.--------------------------- ----- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- -a, .:. . -------------------•------------------------------- DATE------Z-:?-�F^`�/-----------•--------------- <br /> REVIEWED BY F------------------ ----- ------ DATE---------------•--------------•--------------------------- <br /> BUILDING PERMIT ISSUED----------------------------------------------------------------............----...................................... DATE------------------------------------ ------------------------ <br /> Alterations and/or recommendations:--------------------------------------------------------------------................-----------._._....._ ................ --------------------------------- <br /> -------------------------•---•---•----------------•--------••-------.-----•---------••----------•-------------------------------------------•-------------------•--•---•-----•---.-----•-------------------------------- <br /> ----------------- <br /> -- ----------•--------------••-•-•---------- -•-----------_--.---------••--------------------------------------•-------•-----------------------•--••------•---•-••-•-•-•---- •-------•------------------------------------------- <br /> ---------------------------------I----------------------------------------------------------------------------------------------------:---­---------------------- <br /> -----------------------•-------- .--•----•--------------------------•------------------------------------------------------------------------------•----------••--------------------------------------------.-. -------------------- <br /> .... -- - ------------ -•-- ........ --- .. ---. .---------------­----------- .....---... ..---------------------------------------- <br /> FINAL INSPECTION BY: !lc ............. Date --�"�"---� �--------•-------------........-.....----... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West oak Srreet 1.44 Sycamore Street 205 west 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 5-99 2M 6-61 ATLAS <br />