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APPLICATION FOR SANITATION PERMIT Permit No. .lQ. . .�___. <br /> l�" 1 (Complete in Duplicate) �1 <br /> Date issued ----�J-�- ----- <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 Ordinance o. 549. <br /> JOB ADDRESS AND LOC " ......�---- ------?` w G <br /> --- - <br /> Owner's Name_ __________________ ------------------- ••-•--------------------------- --- - -----------------•--------=--------._. Phone- ---------------------------------- <br /> Address 1'1( - <br /> --------------- ----------------------------------- <br /> ------ -- - --- --- -- -- - <br /> ----------- --- <br /> %Contractor's Namev". -------- --- ---rrn_ - --- -- ------------------- ------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of`living units: ___ Number of bedrooms %?.- Number of baths -/-__ Lot size J40A0 ---------------__-_--._____ <br /> i <br /> Water Supply: Public system 0 Community system ❑ Private Depth to Water Table f9 ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe.8'--Hrdpan ❑ <br /> Previous Application Made: Yes [] .:No' �- New Construction: Yes ❑ No Rr PHA/VA: Yes ❑ No ET <br /> TYPE OF INSTALLATION AND`-SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) f <br /> Sep Tank: Distance from nearest well---,-------------Distance from foundation---------------.___ Material------------------------------------------------- <br /> ' No. of compartments-------------- ------------Size--------------------------------Liquid depth-------------- --------Capacity----------------------- <br /> Dis I Field _ Distance from nearest well___£__.._Distance from fcundation___..e4P--------Distance='to nearest lot line---- 4 <br /> Number of lines------------ __ __ <br /> �______` Length of each _-- Width of trench------,�r_`�_____ -------------- <br /> ------------ <br /> _. _ <br /> Type of filter material---/t�Depth of filter material-___._ _� _Total length___ - Q <br /> �� ��-_� <br /> Seepage it: Distance to nearest well----A41..___...Distance from f undation_a164-___---_.D•st peto nearest lot line__�_._._�- <br /> Number of pits-----/---_________Lining maferial'.F _.,._.----_..Size: Diameter_- �__'_�_;, _�`Depfh___.__ ------- <br /> Cesspool: Distance from nearest well------- -------Distance from foundation-------------------.Lining material------------------------------_--- <br /> ___. <br /> ❑ Size: Diameter-------------------------I----------._Depth------------------------------------------------------Liquid (fapacity---------------------------gals. <br /> Privy: Distance from nearest well-_-.___________---___-___--------------- --•. istance from nearest buMin ---------------. <br /> ❑ Distance fo nearest lot line---------------------------------- <br /> --- --------'-------- --------------------- ---------------------------------------------------- <br /> Remodeling <br /> --------------------------- -------------------- <br /> F , <br /> Remodeling and/or repairing (describe]_______________.____. ' <br /> ----------- <br /> ---- ------------=--------- <br /> - � <br /> -•------------------------------------------- - ---`--------•-- --------------- <br /> - -- ------------------------------------------ <br /> ­,.,,,.., , <br /> - ----------------------------------------------------------------------------------------------------------•----------------------•------------- - - <br /> I hereby certify that I have prepared this application and that the work will be done in-6�cordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. , <br /> �w <br /> (Signed) -----J --- ----- -- -s i r Contractor) <br /> $ $ i �/ <br /> Y•-----------------•---------------------------•--•• --------- -- - ------------------------------------,_{Title)...... - ----• -- <br /> (Plot plan, showing size of lot, location system in.relation to wells, buildings,;etc., can be placed`on reverse side). <br /> FOR DEPARTMENT USE ONLY 1 <br /> APPLICATION ACCEPTED BY------t- ,--9-`-4�- ------------------------------------------------------------------------- DATE--- 3I: <br /> REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE--------------------- <br /> ------------- <br /> f %`-'/BUILDING PERMIT ISSUED------------------------------------------------------------ DATE._ , ---------------------------------------------- <br /> - <br /> ' <br /> Alterations and/or recommendations:---------------------------- f -•------------•-- /- <br /> x <br /> ------ <br /> G - O----------------•----•----------Ar&�H_--------LTMF --- ' <br /> ---------------------------------------------------------------------•-•----------------------- ------- ------------- ------------------------------------------- -- <br /> ------------------------------------------------------ - <br /> f - - - ---------- ------ -------------- - <br /> FINAL INSPECTION - -.s -_.-_-_ <br /> -- - -- -- ------ Date----- -------- -- ------------------ ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street �,132 Sycamore Street M4 North "C" Street <br /> Stockton, California Lodi, California Manteca, California ; Tracy, .California <br /> I <br /> E5-4-2Hi . Revised 1.57 F.P,CO. i <br />