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FOR OFFICE USE;­ <br /> -------- <br /> SE;' 7/f37 <br /> -- <br /> -------------------------------------------- ------ APPLICATION FOR SANITATION PERMIT,., . . .P rmif No. __2- 16.x.-..-1.. <br /> --------------j----. ---------------------------------- (Complete in Duplicate) �. <br /> -------------_-------"__ This Permit Expires 1 Year From Date Issued 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 co inpliance with County Ordinance No. 549. ` <br /> /y C <br /> JOB ADDRESS AND LOCATION----�f --?-------51 /1 / �/ �{ � j4 CfZ <br /> -- --------- <br /> Owner's Name_____ __ <br /> / -------- RSA/ ........ �v - - <br /> , <br /> Address ---------------�- --� _ - ------ � - _ � � <br /> Contractor's Name ------------------------------------ Phone- <br /> 4p- ---- <br /> installation will serve: Residenci Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> 3 <br /> Number of living units -Pumber of bedrooms __ _ Number of bathslot size --------- <br /> - <br /> 4 <br /> Wates Supply: Public'system` Community system ❑ Private ❑ Depth to Water Table ________ ft. <br /> Character of soil to a depth.of 3...feet:._...Sand_❑_._.Gravel.❑ Loam.❑ .Clay Loam ❑ Clay ❑ C]Adobe Hardpan <br /> Previous Application Made: (if yes date____________________) No Sa New Construction: Yes ❑ No E] FHYes El E:1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: f l <br /> Septic Nokse tic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> � .. p , <br /> p from nearest well-----------------Distance from fou dation---�a�--------.Mat rial-&,,v-d_f_C—-t,E ------._----. <br /> No. of compartments-------- Size-:� __ -,___Liquid depth_--_ _---_---------Capacity____r7-014? <br /> Disposal field: Distance from nearest well--- �}_s ____.._Distance from foundation-_---_ / Distance to nearest to ine----/�._. <br /> Number of lines_ _w`="=_ .__ ____ __:t":-_:LengiFiof each lined _ Width of trench.. ___ _..�---------------- <br /> Type of filter materia. .- Depth of filter ma� length___: __ <br /> Seepage Pit: Distance to nearest well----------- ----------Distance from.founda ---------------------Distance to nearest lot'°line------------------ %P <br /> El Number of pits----- ----------------Lining material'----------------------Size: Diameter---------------------_-.Depth_---._.--..-r..____---...--._--- <br /> is 1 <br /> Cesspool: Distance from nearest well-----------------Distance from foundation----------------------Lining material____________________________ <br /> Size: Dian eeter------=-- -------'.De tli_I ------------------------------Liquid Capacity -----------gals. <br /> Priv Distance from nearest well_' ----------------------------------- -----Distance from nearest building ---- <br /> ❑ Distance to nearest lot line- ----------------------- -------------------------------------------------------------------------------------------------------------------- ` <br /> 7 ., <br /> Remodelingand/or repairing (describe)----------------- -------------------- --------------------------------------------•-------•---------------------------•-------------------------------- <br /> ;l. i <br /> -; I f. <br /> ='----------- ----------------------------------------- <br /> r : � i. <br /> ------------------------------------------------------------------------------------------•---------------------------------------------------------•------------------------•-------------------------------- ........ <br /> I hereby certify hat I have repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, St I V , and nd regula ` -of the 'San Joaquin Local Health District. <br /> 5i ne. - ----------------- --•------------------------------------------ ---------- ----------- Owner and/or Contractor <br /> (Signe. <br /> g --- <br /> ------- ----- --------------- (Title)--- - - <br /> (Plot plan, sh i size of lot; location of system in relation to.wells, buildings, etc., can be place on reverse side). <br /> !` FOR DEPARTMENT USE ONLY i <br /> APPLICATION ACCEPTED BY-----C..........ZX �------------------- ----------------------•----------------- DATE---- ) Q' ------------------ <br /> ---------- <br /> REVIEWEDBY----------------------------------------------------------------- ------------------ ------------------------------------------ DATE-----------•-------- -- <br /> BU I LDI NG PERMIT ISSUED--------­---------- -----•-------------------------------------= ------ -------------------- DATE---------------------------------- --- <br /> - --------------------- <br /> Alterationsand/or recommendations-------- -------------------------------- -------------- ----------- ------•------------------------------------------------------------------- -•--•---•------- <br /> r. u <br /> If <br /> --•-•----------------------------------------•---`•---•-------------------- -------------------------------•-------------------------------------------------------------------- ------•---------------•--- <br /> w. <br /> FINAL INSPECTION BY:.. Cl ----- Date I ..'. .. - <br /> ----"------ ---- ---• <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Mpnt, cCa�lifornia Tracy,California <br /> ES 9 REVISED B-5B 3M 3-63 F Pmo. r <br /> a _ r <br />