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FOR OFFICE USE: <br /> r�- i`G rC y <br /> � - o <br /> APPLICATION FOR SANITATION PERMIT Permit No. .19: __. ...... <br /> ------------- -------------------------------------- <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 the work herein described. <br /> This application is made in compliance with County Ordinanc No. 4. <br /> JOB ADDRESS AND LO TION_ Q. a 'P <br /> Owner's Name_ -------- --------- - --- ----I 2 -- - --------------­--------------------- -------------- ------ Phone---------------._........------. <br /> Address ------------------------------------------------------•------------------------.....----------•--------••---••--•••---- <br /> Contractor's Name... ------- -- Phone <br /> Installation will serve: Residence VApartmerif House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> -/ 0 <br /> Number of living units: __1__ Number of bedrooms _? ,. Number .of.baths /- '----Lot size .-(�� AJ ............................. <br /> Water Supply: Public system (Community system ❑ Private ❑ Depth ro Water Table 455-�? ft. <br /> t: Sand Gravel Sand Loam Clay Loam Clay ❑ Adobe[�I"ardpan ❑ <br /> Character of soil to a depth of 3 foe Sa ❑ ❑ y ❑ y ❑ Y <br /> Previous Application Made: (If yes,date--------------------) No E5`� New Construction: Yes ❑ No Zr�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.) J. <br /> Septic 'tank: Distance from nearest w I---_ -----Distance//fpm fr�oo/unndlation_____le_...__.Mat-al__ _------ ._. <br /> UK No, of compartments---- ----------------•-$ize_ �T. _T«--._..Liquid de/p��h---� �--------•-Capacity..(�t_.�, ....--- <br /> Disposa�ield: Distance from nearest well---_—_____Distance from foundat' n__-_•4*7--____Distance to nearest lot line.4�+...__..... <br /> []� Number of lines________�_____ !i Length of each line_� �_____ Width of trend _____________ <br /> Type of filter material,�g � _Depth-of filter material___- ------------Total length_____ _.�_____________________-_____ <br /> t <br /> Seepage Pit: Distance to nearest//well-_--_+"----------Distance fr m foundation____ a......DistJ�nce to nearest lot line__e� _-___-- <br /> 1K. Number of pits......ac_____________Lining material---/�0_ _ ._Size: Diameter__S—._ ......Depth-_.___...._____-.-- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation_....---------------Lining material__._-_-____---_-_-_________-____----- <br /> Size: Diameter--------------------------------------De th------=---- ----------- ----- ---Liquid Capacity gals. <br /> Privy- Distance from nearest well-________________________________.__- ----.Distance from nearest building______-__._----____-_________--._..___._. <br /> ❑ Distance to nearest loft line----- -------------------------------------------------------------••----- ---------- ------------•----------------.----------------------- <br /> Remodsiing and/or repairing {describe: ••-------•--•----------- .................. <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 r es and regulations of the San Joaquin Local Health District. <br /> (Signed)---------- �- <br /> --- -- --------------------- -- -- ---------------•- --------------•----------IOwor Contractor) <br /> By----------------------------_---------------------------------------------- --------- ------ ----------------------(rtle) r1 ...... ------ <br /> (Plot plan., showing size of lot, location of system in tion to wells, buildings, etc., can be placed on reverse sidel. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - -- --------------------- DATE �� �_.�a <br /> REVIEWEDBY------------------------------------------- ------------------------------------------------------•------------ DATE---------------------_----------•------------------------ <br /> BUILDINGPERMIT ISSUED-----------------------------------------•----------------------------------------------•---------• • DATE------------------------------------ •---•----------------- << <br /> Alt e af-sons and or recom ndations:--------- ------- --------- ---- <br /> f � .__.. _.. �__.... -----•------- <br /> FINAL INSPECTION BY:---- ----- Date " Z <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9Th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 2M 5-62 ATLAS <br />