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r <br /> APPLICATION FOR SANITATION PERMIT .,.t,,,,,,..Permit No. t.(. <br /> a),W,�• _ <br /> fete in D Hca Date Issued <br /> Application <br /> lishereby made to he San aquin Local Health District for a permit construct and install the work herein described. <br /> This application is made in comp' with Coun .•__r_d.ia,ance <br /> JOB ADDRESS AND LOCATION.__ = " <br /> ------------------------- - --------------------------------------------- Phon ------ <br /> Owner's Name----_-_ __9 ,r ------------------------------------ <br /> Address <br /> 1� T <br /> -------------- -------- - �-6-..------------ (J <br /> --------------•- Phone <br /> Contractor's Name----- -- <br /> . . <br /> Installation will serve: Residence Apartment House ❑ -Commercial ❑ Trailer Court ❑ Motel [I Other ❑ F <br /> Number of living units: J---- Number of bedrooms-- Number of baths /---- Lot size <br /> Water Supply: Public system Community system [I Private F1 Depth to Water Table4jft. 4 <br /> Character of soil to a depth of 3 feet: Sand F] Gravel F­1Sandy,Loam El Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ElNo*—New Construction: Yes ElNo)6"—FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within.200 feet.) <br /> i Distance from nearest well----------------Distance from foundation----------------.---Material—--_..------.-------_-----_------------------. <br /> No. of compartments-- ------•----------------Size-------------------------------Liquid depth--------------------------Capacity---------- <br /> os�l d: Distance from nearest well-,l -: Distance from foundation-__-_--_-- <br /> ------Distance to nearest lot lin�,e---A------_-.-- <br /> r <br /> i <br /> Number of lines------_/---- _--Length of each line-- ---- _-- Width of trench--- r ------------------•-- <br /> Type of filter material-_ -.-.-Depth of filter material---.--_ - ----1--Total length--__�b4------------------------------- <br /> Seepa e Pit: Distance to nearest well--_.-- Oiz4�__Distance fro foundation--- -_-�-_--.Distance to nearest lot line----b--.---_ <br /> Number of pits.._.----------------Lining materiaL_ 4 .- _ _ _ Size: Diamete _ - _ Depth_-- 6 <br /> v <br /> - -------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation.------.---_--.--_ ming material---------------.-----------------.--. Gj <br /> ❑ Size: Diameter---=----------------------------------Depth---------------------- ----------Liquid Capacity------------------ ---------gals. <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 /> --------------------------- <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaq uin County <br /> ordinances, S la nd rules and regulations of he an Joaquin Local Hee{th District. <br /> ]� + ,_ r Contractor] <br /> Si ned��_' -�R---11 - ------- <br /> By: <br /> A _ ��° <br />{ ( 9 ) r <br /> - ------(Title)-- -------------- ----------------- - ------------ <br /> (Plot plan, showing size of lot, location of system in relation t ells, building , etc., can be placed an reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> -------=-------------- ------------------- DATE------47_l q_ _ ---------------------- -- <br /> APPLICATION ACCEPTED 13Y___�,_L�_ ��-'--------- ----------- - --- <br /> sREVIEWED BY-------------------------------------------------------------------- ----------- -------------------------------------------- DATE--------------------------------------.-------------------- <br /> BUILDING <br /> •----------- <br /> BUILDINGPERMIT ISSUED------------------------------ - ----- ----------------------- DATE------------------------------------------------------------- <br /> Alteration) and/or recommendations----------- ------------------------------------- -...----------------------------- -------------------------------------------------------------------------- <br /> ----------nlo-rA = ° �° � ------ <br /> ---------- <br /> ---------------- <br /> -- <br /> ,lf-cr <br /> - ------ ' j-� <br /> ----------------------------- --------- <br /> ------------ <br /> /,� <br /> FINAL INSPECTION BY:------::L_ -------- <br /> - --------•--- Date------ ---�f---�'ir �------- -------------------------- <br /> SAN <br /> ----------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California <br /> Lodi, California Manteca, California Tracy, California <br /> ES-4-2M , Revised 1-57 F.P-M <br /> 4 <br />