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FOR OFFICE USE: r <br />---:--------~ --- ---------------- Permit No. .;/-., _� <br />--------------------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT <br />---- ----------------------------------------- <br /> -------- (Complete in Duplicate} Date Issued <br /> ------------------------------------------- <br /> 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 pfian et s Q2inje <br /> N �49. ve = le,027 <br /> 11 09. <br /> JOB ADDRESS A LOCATION_ 407 <br /> __ l <br /> - . . <br /> - L <br /> Owner's Name_ _ ------f- - - - -- - /f------------------------------------ ---- - ------ ------------ ------ <br /> --- Phone-_-------=---------------------- <br /> ----------- ---------•-------------------------=----- <br /> Address-------------------------- - ----•---------------------- <br /> Contractor's Name.--- ----- ----------- •----- -------- -------- Phone----------------------------------- <br /> Motel Other <br /> Installation will serve: Residence �partment House ❑ Commercial E] Trailer Court ❑ ❑ [I - <br /> Number of living units: <br /> --- Num'ber of bedrooms -5-- Number of baths _ :- Lot size _ -- ✓ <br /> Water Supply: Public system ❑ Community system ElPrivate 21-'-Depth to Water Table t. <br /> Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam ❑ Clay Loam [I Clay ❑ Adobe❑ Hardpan ❑ I <br /> Previous Application Made: (If yes,date-----------=--------) No EZK New Construction: Yes to ❑ FHA/VA: Yes Z�_—No ❑ <br /> s <br /> TYPE-OF-'INSTAL-L-ATION AND SPECIFICATIONS:— <br /> (No septic tank.or cesspool permitted if public sewer is available within 200 feet.)! <br /> fC, ��pp <br /> Septic Tank: Distance from nearest well-_-._d ___.Distance from foundation_- Mate�al__C�r�� - ' 'L <br /> . _ ��/r � Liquid depth _f p Y �� <br /> No. of compartments_ Size /.. - Ca acit . -- <br /> �� ---"-----Dance to nearest low line. ----------•-• <br /> Disposal Field: Distance from nearest well: ._o --..:-`.Distance from #oundati n�-- _ ����' <br /> Number of lines------ -Len th of each line_ _.------------------Width of trench- � ----- <br /> g <br /> Total len th-- ---�L�`-�-- -------------- -- � t <br /> Type of filter material__ ._ Cr Depth of fsifer material---- g <br /> __ <br /> Seepage Pit: Distance to nearest..well___--------------_--Distance from foundation-----------____.___.Distance t-- nearest lot line_.-__-------__-- � <br /> Number of pits. -----'--------- ----Lining material-------------- ----- -Size: Diameter--------- ---------..Dept - ---- -------------------------- <br /> El <br /> --------•---- - - -- r I <br /> :I <br /> Cesspool: Distance from nearest well-___.------_._Distance from foundation--------------------Lining material-------------------------------------- <br /> Size: <br /> ___..._----_ .---____--..-_-------__. - <br /> ❑ Depth---------------------------- ----------------------Liquid Capacity.-,--------------------------gals. <br /> Size: Diameter------- =------------------------------- > <br /> Privy: Distance from nearest..well---------______.____----.-_------------- ----Distance from nearest building__:-_-__---___._-------------..:--------- ' <br /> ❑ Distance to nearest lot line----------- --- ------- ---------- -. ------------------------- ---------------------------------- <br /> Remodeling and/or repairing [describe]:--- <br /> --------------•--------------- <br /> ------------- -------- <br /> -------------------------------- <br /> ---- ----------4 <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 ules and regulations of the San Joaquin Local Health District. <br /> { ✓ ` _Vawma:bd]or Contractor} <br /> (Signed)- ----- -�-- -- -- - --- --- [�"----1-- --- -- - <br /> r ------ � - - - -�- - � ---=- ------------- <br /> (Plot plan, showing size of lot, location of syste relation to wells, buildings, etc.,"can be.placed an reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----7(_R—,_C7 --------------------------------------•---••------------- DATE----- -- - 1-�-- --- �-- <br /> REVIEWED BY--------------------------------------------- -------------------------------------------------------------------- <br /> DATE ------ -------------------- <br /> BUILDING PERMIT ISSUED------- ----------------- ------ <br /> - - -DATE---------- <br /> --- ----------------------------------- ---------- <br /> Alterations and/or recommendations:-- -----•- ----- --------- --------------------------' ------------ ---------•-"- ------------------------------------ ---------- <br /> --------------------------- ---------- --- <br /> -------------------------------------•----------------------­-- __.--------- <br /> ------------ -------------- ------ ----------------------------P---------- <br /> -- - �- <br /> Date----------- �'`------ -- <br /> - <br /> FINAL INSPECTION--B`_: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1401 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street S.- 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED 8-59 3M 3-•63 F.P.CC. <br /> k - <br />