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APPLICATION 'FOR SANITATION PERMIT Permit No4n ­,�_o <br /> 1 <br /> (Complete.in Duplicate) q/ <br /> Date Issued ___._____ ---- <br /> i <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 <br /> hhjCounty Ordinance No. 549. <br /> l JOB ADDRESS' AtTD LQ,CATION`------ <br /> cf�� <br /> Owner's Name-' (lhr , ------------------- Phone-------------------- <br /> Address!----L9.--&-3� -" -----------------------------------------------•--------•=-`------------------ <br /> Contractor's Name----6-fx.--- -------=--------------------------------------------------------------------------------- -- - ---------- Phone----. ---------------•----- <br /> Installation will serve: Residence ❑�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> 1 <br /> .k, Number of living units: ___[__ Number of bedrooms _Z- Number of baths ___1-.-. Lot size _ <br /> i Water Supply: Public system '® Community system ❑ Private ❑ Depth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑. Clay Loam ❑ Clay ❑ Adobe ardpan 11Previous Application Made: Yes E] No E] New Construction: Yes +M No ❑ FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIF[CATIONS: 10-10L.I&A <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well °"�`�Distanc from foundation_ _ ____________Material___ _._"'fit_._______________ !"` ____. : <br /> v�•: No. of compartments_____. -_ _ ' <br /> -_Size X� � Liquid e th Capacity'� 1 . <br /> Dispo I,Field: Distance from nearest well ._ Distance from foundation _t�F'--Distance to nearest lot lin <br /> 11 <br /> [ Number of.;lines-----___-_,e�l[� , -- Length of each lirie--------____________ __r_`__-.Width of trench._____.___.!_____ <br /> Type of filter materic f4�!! _____ Depth of filter material_______ _X______-Total length------------------�O a--________- cA_ <br /> Seepage Pit: `,Di,tanc /to nearest well----------------------Distanx,ce from foundation-------------------.Distance to nearest lot line____-____________ h/ <br /> ❑ Number of pits-------------- -----Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from,nearer#_:well__ ___. !Distance from foundation---_----------_----_Lining material-________..___.--__._____________._. <br /> ❑ Size: Diameter "e i - Depth--------------------------------------- GCapacity--..------------------------ <br /> _ � _ ___.____._Liquid gals, <br /> t Privy: Distance from Distance to nearest loell/r ---------------------------------------Distance from nearest building-----------------------------------------. <br /> N.. #N . <br /> L ❑ ----------------------------------------------------------------- ----------------------------------------------------- <br /> Tike_ -------------- -' - . <br /> Remodeling and/or repairing (describe}:--- ------'- ` --- '----=--------------------------------------------------------------------------------------------------------------------------- <br /> -- ' �-\ <br /> _______._.__________________________.____-.__________________._________________.___._____-- -_---'_!___---.�______________________-_____-_________-____-___________________________-_______-______________--_______________.._ <br /> _____________S_: -__._._.---___________-_______ <br /> ___________________________________________________-..____________________________ ________________.._______________________,________._____________.____.._.. <br /> I hereby certify that I have prepared this-application and that the work will be done in accordance 0ith San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> � W- j'� <br /> IF <br /> (Signed) -�-- --a1-- ________________Owner and or Contractor <br /> IBY: ------------------------------l ---------------------------------------------------- (Title) -------------------=---- °-------------- <br /> 4 (Piot 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 /> IAPPLICATION ACCEPTED BY------------------------------------------------------------------------------------•------------- DATE n..__---------------------------------------------------- <br /> REVIEWEDBY---------------------------- ------- ------------------- -------------------------------------- DATE-- - ------------ --------- --------------- <br /> BUILDING PERMIT ISSUED-------.�_J----------------------------------------- -- <br /> DATE <br /> - ---------------------- <br /> Alterations and/or recom ndations---------------- -------------------- ------------------------------------------------------------------- _ <br /> ---------- -------- ----- -------- - -------------------------------------------- <br /> -------------- - --------- ---- <br /> ---- -- <br /> -0----- <br /> --------------------------------- ----- � Y----- -- ---- ------------------------- <br /> - <br /> ------------------------------------ -------- ------------------------------------------- --------- - ----------------- <br /> FINAL INSPECTION BY:.-. Date------/ -- �4' --------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> s Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9--2M , Revised 1-57 F.P.CO. <br />