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� FOR OFFICE USE"— ' <br /> ' <br /> ------ -----`=--------------- 3 APPLICATION FOR SANITATION PERMITPermit No. <br /> T=" -- ------------------------ -------------------- <br /> ---------------------_-_-- ------------------------ " (Complete in Duplicate) Date Issued ._� _-L_ _` <br /> _"_____________------____�'-__-__._-___.."~_._____-__-. " rtv�..,This Permit Expires 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 LOC TION ( -7_t/ - ......... <br /> t <br /> Owner's Name--------- '-•-------•----------------------------------------------- Phone. " I <br /> :. ,Address nn -- -•----------------------------•------------- •-------- ------ <br /> �u A ---_---•-- -----------•-------------_ — " <br /> Contractor's Name -----------------•--- --• - '. .........---------------•---------- <br /> Phone <br /> Installation will serve: 'Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel.❑ Other ❑ <br /> Number of living units: __ _. Number of bedrooms ?_ Number of baths J____ Lot size . .' '_X��:3�'"_____________________________ <br /> i <br /> 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 iardpan ❑ <br /> Previous Application Made: (If yes,dote---------- 1, No QT' New/Construction: Yes ET--No ❑ FHA/VA: Yes?2-' No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> s (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: 'Distance from nearest well__:__`"` _Dis#ancg f om.foundation----,� _./.___Mat al __ L f `'"-----___ <br /> 11 <br /> No. of compartments---- -------- . __. ._::__Liquid depth____ ___ ,____.___-___Capacity__ *_e?-_.___ <br /> Disposal Field: Distance from nearest well.`.-+7=_.Distance from foundation___---------Distance to nearest lot line_________ <br /> �. <br /> Number of lines______'_ Length of:each'dine a e- Width of trench-_.r ____------ <br /> ____________ <br /> _---. �, <br /> Type of filter material C_Depth of filter material___ __________-Total length___A�'_�______________________ - <br /> Seepage Pit: Distance to nearest well------"""'..---Distance from foundation__/401__..:'_.Dist ice to nearest lot line_ ______ <br /> Number of pits___..e------------Lining material__,�L9kr-rSize: Diameter_ <br /> ' Cesspool: Distance from nearest well-----------------Distance from foundation_----:-" ___ `.Lining material_._.---_.____-____-________________-_. <br /> 1. ❑ Size: Diameter--------------------------- ----------Depth---------------------------------------------:---'-Liquid Capacity--------------------------..gals. <br /> Privy: Distance from nearest well _______________!_"___________...___--_--__.-__-Distance from nearest building_____.-._-:_-____________________---_-___. <br /> "'Distance to nearest-lot'line-------------- � -------------------------- ----------------------------- ---------•• ---------------•------------------------ ----- <br /> 3 ` <br /> Remodeling and/or repairing (describe):--------------- — ------•--- ------ ' -------= --•-•--- <br /> = -------------------- <br /> ------------------------------------------------------------------ <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, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)------------------ -;�� /or Contractor) <br /> $Y:---------------------------------------------------------- •------------------- -- •--- ---- ---------••-----------{Title)-- - - -- - ------ ----....-....------------------ <br /> (Plot <br /> -- -------(Plot plan, showing size of lot, location of system in reVA to wells, buildings, etc., can be placed.on reverse side). <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- _.__.__�/-�r� Gcl --------------"------------------- DATE -2-- -(9 ----------------------- <br /> REVIEWEDBY-----------------------------------------------------------------------`----°---------------------------- DATE -------------•-•-= <br /> BUILDINGPERMIT ISSUED----------------------------------------------=--------------—-------------------------------------- DATE--------------------------------------------------:.-------- <br /> Alterations and/or recommendations-----=------------------ -' ---------------------------­_.=--------------•------------• ----------------­------- ----------- ---... <br /> ----------------------- - -- ------------• ---------" •----------- ...----------------------•--"--------•-.................... <br /> i r - <br /> t!-_- ------ - -----•-•-------------- --------------"-"_---.---------- <br /> - -- ---- - -- - <br /> FINAL 'INSPl=CT10N BY:--------`--.. .--`----F-•-°=��-`-----=�'---^�l Date-------------------- ----------------------- --------------------------••- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street ,,1.24 Sycamore Street 205 West 9th Street <br /> } <br /> Stockton,California Lodi,California ,� 'N teco,California Trocyr California <br /> I CS-9 REVI6EG 9.59 F.F.CO.2M 6-60 <br />