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OFFICE USE <br /> �r� S -- -------------- � — --- y <br /> __________________..____.________ �.. APPLICATION FOR SANITATION PERMIT Permit No. __ _ ------- <br /> -------------------- ----- - ---------------------------- {Complete in Duplicate} <br /> Date Issued <br /> ---------- --- --- -------------- This Permit Ex ices 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 Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION-----------9.37__________S ,y f I r <br /> `{------------•---•-------------------------------------------------------•------------ <br /> Owner's Name i-n � S---T�--------------- ''2 e��,,y`� ...//a-±--, f Phone------- <br /> Address `'-3Jr - `5- = 5--`- `` s �1 .` -�' <br /> f <br /> Contractor's Name---- /f� .�`----- •%-- --------------- <br /> `� Phone. S 7 <br /> Installation will serve: Residence [T Apartment House ❑ ' Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __1___ Number of bedrooms -__ _-_ Number of baths .__!_._ Lot size -------- <br /> - -- -- -- ?___.__________._____.____ <br /> Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table A_rft. <br /> Characfer• of soil to a depth of 3 feet: Sand ❑` Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe d" Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No P4 New Construction: Yes K- No ❑ FHA/VA: Yes ❑ No Ej-- <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is availa6le within 240 feet.) <br /> Septic Tank: Distance from nearest weltn _Distance from foundation----- v________-Material___.- -------------- <br /> No,c <br /> ------_. - <br /> No,c of compartments-------Z_-------------- X f_�,iC___9__�-,_--Liquid depth......'Y`--------------Capacity-- _u- <br /> Disposal Field: Distance from nearest well.Aro.�+_cr_Distance from foundation___1a----------Distance to nearest lot line_-1w------- <br /> 21 Number of lines--------------/-------------------Length of each line------------------------------Width of trench------ ----------------------- <br /> Type <br /> Type of filter material_____�i�,~_l<----Depth of filter material ............ length--------Y4?_r_______________________ <br /> Seepage Pit: Distance to nearest well--- Distance from foundation----!...............Distance to nearest lot line__-f__-_.._ <br /> Number of pits-----_/-------------Lining material-----/�GDiameter__­ <br /> 3.3 Diameter__ 3.3_._.__.----.Dept h------�.5'--------- <br /> ----------- <br /> Cesspool: Distance from nearest well---------________Distance from foundation--------------------Lining material-______-___________.____.______-____ J j <br /> ❑ Size: Diameter------ -----------------------------.Depth----------------------------- ---- -----------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well____________ ___________________________-..___._Distance from nearest building------------------------------------------- V) <br /> ❑ r` <br /> nearest lot jme i <br /> Remodelingand/or repairing (describe):------ --------------------------------------------------- --------------•----------------------------------------------------------------------------� <br /> ------------•--••------------------------------------------------- ------------------------------------------------------------------------------ O <br /> ----------------------------------------------------------------------- ----------- ------------•---------------------------------------4 <br /> y =-------------------------------------------------------- ------ ---------- q --- <br /> I <br /> hereb certifythen[ have t erect this application and that the work will be done in accordance with an Joaquin Count <br /> ordinances, State laws-, and rules and regulations of the SanJoaquin Local Health District. <br /> { - Owne ``r <br /> (Signed) � -- ----- ------ -f ( rand/or Contractor) ; <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 i <br /> APPLICATION ACCEPTED BY---------._4 _^________________________ .: "' <br /> DATE. - ------------------------- <br /> REVIEWEDBY------------------------------------------ -- ------------ ------------------- ---------------------------------------------- DATE------. ---------------•----------- ------------------- <br /> BUILDING PERMIT ISSUED------------------------------------- ---------------------------------------------------------------- DATE <br /> Alterations and/or rete dafionsi---- �----+-------------------------------------------------------------•------------------------------------------------------ <br /> ---------------------------------- --------------------------------- <br /> ------------------------------- --------- -•--------•------- ------------------------- --------- ------------------------------------------------------------------------------ ---- -•---- <br /> - ---- ---- <br /> - i <br /> FINAL IN5PECTION BY:---,----;"-------L!---------------------------------------- ---- Date------- --- -------- ------------------------------ ----------------- ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Mantecar California Tracy,California <br /> F.P.CO. 4'ti•� ��. j <br /> j <br />