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POR OFFICE USE: <br /> 11 10 ��¢_3/ <br /> ------------------------------------------ -------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> 16 <br /> -------------- (Complete in Duplicate) <br /> --------------I-- ------- ----------------- . Date Issued -------- <br /> ------ --- This Permit Expires I Year From Date Issued <br /> ------------------------------ ------------- <br /> Applica.tion 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 /> W------------/4...... --------------- <br /> JOB ADDRESS AND-d.00ATION_A&,/4_r_�_7-11 -------------------------- <br /> ------------------ <br /> -------------------------- I - <br /> Owner's Name-------- --------------- --_------------------ ---------- e------------------------------------ <br /> 16 1 ----------------- <br /> ---- A0. i------------------------------------------------------------ <br /> Address--------_----------------- - ----- <br /> Contractor's Name----1-3 ------- -- ---------------- Phone..-- <br /> ----------- <br /> Installation will serve: .'Residence gff Apartment House E] Commercial E] Trailer Court 0 Motel [I Other [I <br /> Number of living units: N,m'ber of bedrooms -------- Number of baths -------- Lot size ----:--------------------- ------------------------------------ <br /> Wafer Supply: Public system E] Community system El Private'RT"'Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand [] Gravel [] Sandy Loam E] Clay Loam [] Clay Adobe }Hardpan El <br /> Previous Application Made:-(If yes,date--------------------) Noo New Construction: Yes 0 No FHA/VA: Yes D No El <br /> TYPE'OF INSTALLATION AND SPECIFICATIONS: <br /> (No-septic fa'n'Vor cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from/nearest well!_ ____::- --Distance from foundation--------------------Material------------------------------------------------ <br /> El No. of compartments----------------=-- ----Size--------------------------------Liquid depth--------------------------Capacity-------------------r <br /> ' _50 <br /> Dis field: Distance from nearest well .. Distance from foundation___. -a-'------Distance to nearest lot <br /> 7XNumber of lines--- ......:-- -------- Length of each line.- ------ -----------..Width Width of trench------7*..--------------------- <br /> Type of-filter --Depth of filter material------&..........Total length--------&Z9 e-------------------------- <br /> ' i. - " <br /> See �Pif: Distance to nearest ' ----------Distance from fTundafion-----/0--/__Distance to nearest lot line..-_______--- <br /> EI e. <br /> Nulm' ber'_of pits_­��/----------*-p Lining maferial__/Une�____--Size: Diameter_____TJ----:-------Depth--- 21.15--------------- - -- <br /> Cesspool: Distance from nearest well-______________....------------Distance from foundation _.. --_---.._____.Lining material_._-----.---__-----_____.____.___---- <br /> ❑ Size: Diame --------'--;---------- ---- ------Depth :-.Liquid Capacity----------------------------gals <br /> - --. . <br /> Privy: Disfan'Ce .from nearest well------------------ ------ ----------------------Distance from nearest building_______-----_-._______-,_____.._.------. X <br /> ❑ <br /> uilding---------------------------------- ------- <br /> 0 Distance to nearest lot line----------------------- --------------------------------------------------------------------------------------------------------------------- A <br /> Remodeling ancl/,�r -repairing)(clescirib'e): -------------------- -- -------------------------------------------------------------------------------------------------------------------------------- <br /> ------------- <br /> ------------------------------­----------------------•--------------------------------------------------------------------------------------------------------------------------------------------------------% <br /> . <br /> ; t I, I I ------------------------I-------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------I--------------------------- <br /> j ----------------------------------- -------------------- <br /> -------------------------------�-� -:------------------------------------------------------------------------------------------------------------------------ .4 <br /> I hereby certff9',!fhaf'I have,prepar'eJ this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, SfafWlaws, and rules nd regulations o the San Joa uin Local Health District. <br /> -------- ------------------------------<__SN7i_Wr and/or Contractor) <br /> (Signed): <br /> By-------- -- --- -- <br /> ----- ---------------------------------------------------(Title]-------------- <br /> --------------(Tif Ils)----------------------- -------------- --- - ------------ <br /> (Plot-,p showing size of lot, location 0 system in relat n to wells, buildings, etc., can be placed on reverse side). <br /> 10 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- ----- -- -- ------------------------------------------------------ DATE---- --------------------- ---- <br /> REVIEWEDBY--------------------------------------------- ---- ---------------------- - ---------------------- ------------------------... DATE------ ---------------------------------------............... <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE <br /> Alteraatons and recommendations:-------------- -------------------------------- -------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------­----------------------------------------------------------------- -------------------- ------------------------- ....... ------------------------ <br /> k <br /> ----------------I------------------------------------------------------ ---------------------------------------------------- -----------------------------------------------------------------------------1-------------------I <br /> --------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------- ---------------------- --- ---------------------------- ------------------ -------_------- ---------------------------------- ---------- -------- - ------ <br /> ---------- --_----------------------------------------- <br /> FINAL INSPECTION BY:- - -------- _ - --A- --- - ------ --------------------- Date---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hatellon Ave. 300 West Oak Street 124 Sycamore Street .205 West 9th Street <br /> Stockton,California Lodi,-California Manteca,California Tracy,California <br /> ES 9 REVISED B-59 2M 0-621 F-F-120- <br /> L <br />