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FOR OFFICE USE: — <br /> a_ <br /> APPLICATION FOR'SANITATION PERMIT Permit No. <br />-------- t-1- - '- -6' -------`-- _1_ r'7 (Complete in Duplicate) <br /> ---- ------.-------------.... .......'r.___ This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install t>a work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION-------.__ <br /> - y ` f <br /> Phone-!_.-- ...Owner's Name................ <br /> ------ -/ --Address------. -------------------- ..... --_ <br /> a <br /> ,� . <br /> Contractors Name------ ----------r-•-------••/ Phone................ <br /> d <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial [Trailer Court ❑ Motel ❑ Other ❑ I <br /> Number of living units: __ ___ Number of bedrooms --------- Number of baths _� Lot size ------//____,�� i'-••---------------- r <br /> Water Supply: Public system ❑ Community system ET___P`rivate ❑ Depth ro Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application .Made: ;If yes,date...... -------.-----) No ❑ New Construction: Yes M,-Iqo ❑ FHANA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> i <br /> Septic T k: Distance from nearest well_______Distance,from�foundat n______-j..�____.Material_�_ _ _________ ___________ �_ ___. <br /> No. of compartments--------------------------Size__ --9____ S__Liquid depth---------- ____------Capacity......--_-__-- ---_-- <br /> Disposal Field: Distance from nearest well_J____( .._.Distance from foundation____. -------Distance to nearest lot lin `�/ <br /> cam -- Fr .. <br /> Number of lines................I____-_-_._ _. Length of each line---------�,Y--__________.Width of french._. 2. ____.-------�---- <br /> Type of filter material._.._ � L.Depfih of filter material_.__._./_ __`"Total length_....._.�'�._.......� <br /> �C_-�......Distance to nearest l i�____ ...... <br /> Seepage Pit: Number of nearest III__ _Linin mfieral Distance frvfo5 ze:nDiamett:r._..��_.-•_--_Depth................................. <br /> ©� P 9 <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining --------------------------------- <br /> El <br /> Size: Diameter---------------- --------------------De th----------------------------------------------------Liquid Capacity gals. <br /> Privy: Distance from nearest well-----------------------------------_-------------Distance from nearest build ing------------------------------------------ I <br /> ClDistance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):---------------------------------------------------------------------•-•--------------------------------------------------------------------------------- <br /> -------------------------------------------------------- I <br /> --------------------------•- -----------------------------•---•------------•----------•-•-------------•------•-•-----------------•--•------------------------•----•---•-•-------•----........----•--------------------------- a <br /> ___________________________________________________________________________________________________________----»____________---_--_-_.--_________....-.__.__....________________-___•---_-_________._...-_-__.____.--__ 3 <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, an les and re lations of the San Joaquin Local Health District. i <br /> (Signed) (Owner and/or Contractor) <br /> - .-- -------- ------ -------------------------------------- <br /> By:---- -----•-•-- -------------------------------------------------------- ---------------------------------------------------------(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-------------- - --------- ------------__-L--------------- DATE-------Z "--1------ <br /> REVIEWEDBY-----------------•----•------•--------------- ....-- --• DATE------------------------------------------------------------ <br /> BUILDING PERMIT ISSUED................ -..... DA•TE------------------------------------------'` ------- <br /> Alterations and/or repommend tions: -- --- S = - ,- � .......DATE <br /> aS- i<�eft l ......................... <br /> �,//` '�• � _a­ <br /> ------------------------------------------------------------------------------------ •-•-------------------- <br /> ---------------- --1/-.--_------------------------------------------------------------ ------- -------------- ---------------------­-------------------------------------------------------------------------------------- <br /> --------------------------- ------ . . ----------------------- ------ <br /> FINAL INSPECTION BY: Date / l ----- <br /> --------------------------------- <br /> -------- --- ------------ --------- <br /> Copy -fur Gree,+ Uo.:PL2t Pro Ve � e5 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 /> E5 9 REVISED 8-99 2M 5-62 ATLAS <br />