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FOR OFFL(; USE: <br /> Permit D <br /> -------------- No. 1±1 <br /> j-.3 0�r e APPLICATION FOR SANITATION PERMIT ............... <br /> --- ---------------- <br /> (Complete in Duplicate) <br /> --- ----------• -----------1__1___._i... -I----• I <br /> -------------------------------------- -------------- - This Permit Expires I Year From Date Issued Date to Issued I................. <br /> jol - 407,0- 2,2— <br /> Application is hereby made to the Siin Joaquin Local Health District for a permit to construct-and-instalkthe work herein described. <br /> N <br /> This application is made in complianq'e with County Ordinance 0, <br /> - - - --- -------------------------------- <br /> pro <br /> JOB ADDRESS -------1�_ --- -------------------- --------------- <br /> _6UP LOCATJQN-/.. .... ------- ------- ----4,w <br /> Owner's Name----- ------ -------- ------- ------------------------------------------------------------------------- --------------------------- Phone.--................................. <br /> Address------- --1 -1- --------------- ------------- -------------------------------------------------- ..................................................................................­.. <br /> Contractor's Name-------v,-----------------------T4-------------------------------------------------------------------------------------------------- Phone.............. <br /> Installation will serve: Residence�[R—Apartment House El Commercial E] Trailer Court (3 Motel El Other El <br /> Number of living units: J---- Number of bedrooms _-3__-- Number of bathsz... Lot size .... ---________I........... <br /> Water Supply: Public system El Community system ®private E] Depth To Water Table -kD- ft. <br /> Character of sail to a depth of 3 feet: Sand E] Gravel C1 Sandy Loam 0 Clay Loam [-] Clay E] Adobe[Hardpan 0 <br /> Previous Application Made; (if yes,ldafe--------------------) No [!K New Construction: Yes [3--No 0 FHA/VA: Yes E!r- No 0 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> nk: Distance from n, a ............. <br /> Se nearest welly....__-__Distance from foundation--- ---- Material--!/----- ----------- ........ <br /> V No. of compart6rits.........qn.......... Liquid dep�h__f--------------------- pacity.......4T�AP- <br /> i �45P <br /> Dispose j Field- Distance from nearest well__�........Distance from foundation--/a ----------- t line------- r <br /> ...... Distance to nearest lo <br /> ----------------- ' '- ----- ---------- <br /> Number of lines.-..---3--------- ---------------Length of each line_-:30--- Width of french------ <br /> Type of filter maferial..J7ti.-g.-�---------tDepth of filter material---I 8.'.................Total <br /> Seeps Pit: Distance to nearest well-1 ---------------___.____Distance rom f(cunclation-10!......_.Disfance to nearest lot line.-%5----------- <br /> Number of pits---!!.-�--------------Linilng.,rnaferia&-ceA------Size: Diameter___33..............Dept h--------—-—------------------ <br /> from foundation--------------------Lining material-_____.____________-__---_____ <br /> Distance from nearest well__________ _____-- Distance <br /> El .Size: Diameter--"--------------- -------------------Depth--------------------------------- ----------------_Liquid Capacity-------_------------------gals. <br /> Privy- Distance from nearest well---------------------------------------- ------Distance from nearest 6uildingr----------------------------------------- - <br /> ❑ Distance to nearest lot line----------------------------------------------------------------------------------------- ---------------'--------------•----•-------------- w <br /> I Remodeling <br /> ------------------------------------------------ <br /> Remodelingand/or repairing (desclibe):----------------------------------------------------- .......----------------------------------------------------------------------------------------- <br /> - ------------------------------------------------------------I----------------------------------------- --------­----------------­­--------------------------------------------------------1----------------------------- <br /> --------------------------------------------------------I-------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I ----------------------------------- <br /> --------------------•-------------------------------------- -------------------------------------------------------------------------------------------------• -----------........ <br /> I hereby certify that I have pr;pared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulatio of the San Joaquin Local Health District. <br /> (Signed)._!_�------------------------------------------- ... . ----------------------------------------------------(Owner and/or Contractor) <br /> ---------------- --- ------ -------------------- <br /> By:---------:--------------..................I-- ---- --- --- --------- - ------r -------------------------------------------------(rifle)--------------------------------r---------------- -------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYy--- ----- - ----------- DATE - <br /> REVIEWED BY----------------------------- --------------------------------- -------------------------------------------... _-z----------------------- <br /> DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED-------=-----------------------=----------------------- --------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and ........... <br /> /or recommendations:----I — ----------PX -------- ........V- <br /> ---------------------------------------------------- --------------------------------------------------- ------------------------------------ ----------------------------------------- ................................ <br /> ----------- ------------------------------------------------ -------------------------------------------- -----------------------------------­­­--------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------- --------------------------------------*-------------------------I--------------------------­ <br /> ----------- ------------------ <br /> ------------------------------------------------------- <br /> ---------------------------------------­­­..............:---------------------------------------I---------­---------------- <br /> FINAL INSPECTION BY;,e1K. ---------------- Date-------------------------- --------I------------------------------- -------- <br /> . .......... ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South Americom Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVtSED.8-59 2M 5-62 ATLAS <br />