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FOR OFFICE UIE: <br /> ---- - -- --- ---- ------ APPLICATION FOR SANITATION PERMIT Permit No. 12222n.... <br /> ------------------I-------------------------------------- <br /> -- - ---- ----- -- <br /> -----------------I---------­----------------------- <br /> ------------------------------------- --------------- (Complete in Duplicate) Date Issued <br /> - <br /> ------------* <br /> -------------------------­---------------- ,,__This,Permit Expires I Year From Date Issued <br /> 111 <br /> Application is hereby made'to the San Joaquin Local Health District for a permit to construct and install the". drk herWin` scribed. <br /> This application is made in compliance with County Ordinance oto. 549. <br /> JOB ADDRESS AND LOCATION- A 0101. .....V.... <br /> _--------_------------------ <br /> Owner's, Name 6&dl-4.0------- ....... ­-- ---------- -- ----------------------------------- ------ --------------------------------------/Phone--------------------------------•--- <br /> Address-----•- <br /> hone------------------------------------ <br /> - 014 f <br /> Address__- ....... ......;6�.... ......... ............. ........ ........... ...............k............................................................................. <br /> -------- --------- .......................... <br /> Contractor's Name------ ------- --------­------ ------------------------------------------------------------- Phone......... <br /> Installation will serve: Residence PR/e/Apa-irtmen House E] Commercial F] Trailer Court 0 Motel 0 Other ❑ <br /> Number of living units: --I---- Number of bedrooms 2--- Num6Depth <br /> baths ---I--- Lot size ....../12--- ------------------ <br /> Water Supply: Public system E] Community system [-] Private to Water Table ------ ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loam E] Clay Loam ;;/Clay E] Adobe[] Hardpan 0: <br /> Previous Application Made: (If yes,date-..____-.----__..-).-.-) No E] New Construction: Yes Ej No E] FHA/VA: Yes 0 No [I <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation....................Material_---------------------------------------------- <br /> ❑ No. of compartments--------_----_---------Size--------------------------------Liquid clepth...----------------------Capacity----------------------- <br /> po 1 I <br /> Dis Field: Distance from nearest well..:__✓to----Distance from foundation.......ip...1-.Distance to nearest lot line. <br /> ....5--/.... <br /> Number of lines--- Length of each line.-Y- -------------A'------Width of trench..... ­------------------- <br /> ------- ---- ---- <br /> Type of filter material----- __-_-Depth of filter material..._. __.....__.Total length-.--..' _________________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line.................OZ <br /> R Number of pits______________________Liming.material----------------------Size: Diameter__---_____-__.__.-.-_Depth------ --------------------------4wo. <br /> Cesspool: Distance from nearest well-----------------Distance from foundation----- -------......Lining material.._.._.__..._._.___--__ -" <br /> 0 Size: Diameter--------------------------------------Depth----------------- ----------------------------------Liquid Capacity..--------_--------•------gals. <br /> Privy: Distance from nearest well________________________________________________Distance from nearest building:____---____-_- __----..-----_-.---___._..Y <br /> ❑ Distance <br /> uilding----------------------------------------- <br /> Distanceto nearest lot line----------------------------------------------- ................................------------------------------------------------------------- <br /> Remodelingand/or repairing (describe)---- -- ----- _...................................................................................................................... <br /> -------------------------------------------------------------------........ ..... <br /> -------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------- ---------------•-----------------------------I-------------------------------------------------------------------------------------------- <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)........ .... ------------------------------------------------- ---- ne r Contractor) <br /> By:------- ---------- ----------------(Time)------------------ -------------------­ -------- <br /> ---------- ----- -------- .. ---------------------------- ----- <br /> Yion to wells;of system in re lso builditgs, etc., can be placed on reverse side). <br /> (Plot plan, showing size Of lot, location <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- ------_. ---------------------------------------------------------- DATE-----7_.1.__._..�._..j1 <br /> ------------------- <br /> ..__ <br /> REVIEWEDBY--------------------------------------------------------------------------------------------------- -------------------------- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED-----------------------------------------------------------------:---------_--------------------------- DATE--------------------------------------------............ <br /> Alterationsand/or recommendations:-------------------------------------------------------------I-------------...............................................................------------------- <br /> -------------- ----------------------------------------------------------------------------------......................................t...................................................................... <br /> ------------------------------------------------------------------------------------- ---------------------------................................................................................................... <br /> ------------------ ------------------------------------------------------------------ ---­------------------------------------------------------------------------------------------------------- ..................... <br /> ----------------------------------------- --------­---------­----­ ---------------­- .............................................. ----------------------------------------------------------------------- <br /> FINAL INSPECTION -------------------- Date..2___- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazolton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> rg 9 REVISED 8-59 3M 3`63 F.P.00. <br />