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W <br /> FOR OFFICE USE: <br /> -_-. APPLICATION FOR SANITATION PERMIT Permit No. _Z.Z.5�._-3IL <br /> (Complete in Duplicate) <br /> ---------------- 1 This Permit Exoires 1 Year From Date Issued Date r3`st'e6"`_� / ,S/ <br /> --- -----4 - 4 1------------ <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 compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION_ 7_- =-• <br /> -- ---------- --- <br /> Owner's Name----~OA = Gzi ...... Phone./7`e._ <br /> Address------------ <br /> Contractor's Name.. ------------------------•-------------------------- ----- ----- Phone -------------- <br /> Installation will serve: Residence 56 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: --/-___ Number of bedrooms .3--- Number of baths _/----- Lot size ._Y_ __/., _ _._.._.___....___..___.. <br /> Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Pa Hardpan ❑ <br /> Previous Application Made: (If yes,date-----------_--------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: p <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_N.QNA�_.Distance from foundation---L(?_-_--__-_.Material--------------------------v 0 <br /> C9No. of compartments-----Z----------------Size__V/_.i�'X._S-------....Liquid de th______.__.-._--_.--.__ -Capacity.... <br /> q p --- P Y----��-----•-�/ <br /> Disposal Field`: Distance from nearest well_I(�e� _Distance from foundatio __1_0....._......Distance to nearest lot line.....50 �--- <br /> Number of lines----------]___________________Length of each line�_ 3=_`� �--------- <br /> ---------------------- <br /> Type <br /> te-.Width of trench_ .-,__.____._._ __. <br /> ---- <br /> Type of filter material___. C_'_4'_ .....Depth of filter material-./.V_------___-.-Total length__- Q__________________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> r_1 <br /> _-_-_ _---___--❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------------- <br /> Depth---------------------•--------------_--- <br /> Cesspool: Da nce from nearest well________________ Distance from foundation-_:-=---_ -----_ Lining <br /> material <br /> ❑ zeDaeter. ;,-Depth <br /> _ __Liquid Capacity--------------------------_gals. <br /> J <br /> - <br /> rv► <br /> Privy: Distance from nearest well------------------------------------------------- from nearest building ' <br /> ❑ Distance to nearest lot line. <br /> ------•---------•--•--------•------•Remodeling and/or and/or repairing (describe):._____._____.._,___. <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------•-------------------•-------------------------------------•------•-----•------------------------------------------•----•---------••------•----------•----••--•------------------ <br /> I hereby certify #hat have prepared +his plication and th + the work will be done in accordance with San Joaquin County <br /> ordinances, State s, a rules nd regulati sof the San J quip Local Health District. <br /> (Signed)______ ___________ __ ______ _______________ I Owner and/or Contractor <br /> - ---------------( / ) <br /> By:---------------------------------------------------------------------------------------------------------------------------------(Title) <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., canbe placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED �_ . �-`_r_�- ----------------------------------------- DATE_.._=._l 'fin <br /> REVIEWED BY------------------------ <br /> ---------------------­---- DATE.. <br /> - ---------------------------------------- <br /> - ......................................................... <br /> BUILDING PERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE--- <br /> --------------- <br /> Alterations and/or recommendations:--.;-.-.______--.___ <br /> ----------------------------------------------------------------------------------•----------------------------- <br /> ----------------------------- ---------------------------------------------------------------------------------------- <br /> -----------------------------------I---------------------------------------------------------------------------- <br /> ---------- ------------------•-------------------------------------------.-- -------------------------------------- ---------- --------- <br /> FINAL INSPECTION BY:----------6 ---•*--- � <br /> - -------------------------------------- Date----./i�. _�7t-"-'- -•--------•----------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haselton 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 5-59 3M 3-'63 F.P.CD. <br /> w <br />