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F0�F OFFKE USE: <br /> ------------- ------------ ----------- <br /> ------- ------- ---------1------ APPLICATION FOR SANITATION PERMIT Permit No. .../ <br /> . .................. <br /> ----------- - ------------------- (Complete in Duplicate) <br /> I : <br /> This Permit Expires 1 Year From Dalt-e Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District forA, i4ermit to construct and install the work herein d?wc ibed. <br /> This application is made in compliance with County Ordinance 1`46. 549. <br /> JOB ADDRESA� LO QATION... S <br /> .- ..-u <br /> > <br /> Owner's Name--------------- ----1 AP-a-2,---------------- ------------------------------------------ Phone------------------------------------ <br /> Address------------------ <br /> Contractor's Name---------OW-t.A4 <br /> ..F—_K--------------------------------------------------------I------- ------------------- -------------------.- Phone......................... --------- <br /> Installation will serve: Residence Er—A-partment House E] Commercial E] Trailer Court ❑ Motel [] Other ❑ <br /> Number of living units: j--- Number of bedrooms _X_ Number of baths Lot size ----- ------------ <br /> Water Supply: Public system (-] Community sys�tte F1 Private PT"belpfl-i to Wafer Tablw-------- ft. <br /> Character of soil to a depth of 3 feet: Sand e Gravel [] Sand y Loam E] Clay Loam E] Clay ❑ Adobe C] Hardpan 0 <br /> Previous Application Made: (If yes,date___-___--______.__) No E?-' New Construction: Yes Kr-1To ❑ FHA/VA: Yes 0 No Ej'-' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool pelrmitfled if public sewer is available within 200 feet.) <br /> Vo SePticTd'hk: rDistance from nearest 'Well____----Distange from foundation-----le---------Material'r ------ <br /> No. of comparfi-rients--- ---------SizeYXLOX25_.Liquid clepth--- ---------Capacity./ZBP. rn <br /> Disposal Field: Distance from nearest well.5 -0-----Distance from foundation.../0---------16istance to nearest lot line-.�__.__. V% <br /> Number of lines_________________.__..__________'-7— Length of each line-: idth of trench._:____ <br /> ---------- T <br /> Type of filter material-- Depth of filter material------1&7-----------Total length------------_76-157 <br /> ,,Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line_.-_.:___.______ S <br /> ❑ <br /> ine------- ------- <br /> F1 Number of pits- _------Lining material-__-------------------Size: Diameter---,--_-----.----..----Depth--------------------------------- <br /> Cesspool: Distance from nearest well________________Distance from foundation---------------------Lining material____.___-.____._-__.___-__.-________ <br /> ❑ <br /> aterial------------------------------------ <br /> F-1 Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well--- --------- --------------------------------_Distance from ne*rest building________-____-___________--__.-___._. <br /> ❑ Distance <br /> uilding------------------------------------------ <br /> Distance to n 1P rest lot line------ -------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):-_-_7-P--- 5__QPP1Afi_=M_E.A1_r--------;IEX t s_rj_1,je_--r------ _r -------- <br /> -----------------------------------------------=_1---------------------------------------------------------------------------------------------------------------------------------------------------- ......... <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------ <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, an rules and regulations of the San Joaquin Local Health District. <br /> (Signed)---r ------- ---- ---I-------------------------------------------------------------------- --------------------------------(Owner and/or Contractor) <br /> By:------------------------------------------- =- ------------------------------------------------------------------------(Title)-- -- ------------------------ - -- -------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------ --------------------------------------------------------------- DATE_----le-.7-V. ......4 <br /> REVIEWED BY <br /> ..... DATE------------------------------------------- -------------------------- <br /> --------_----------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------------------- <br /> Alterations and/or recommendations:--- --------------------- <br /> ------------------------------ ----------------- <br /> --------- ---- ... ..... <br /> ---------- ------------------------------------------------------------ <br /> ---------------------------- <br /> -------------------------------- ------ - ------ ------------- -------------------------------------------------- -------------------------••---------------------------------------- <br /> ------ - ----- <br /> -------­-----------I-------------I-------------- <br /> -------------------___----- -- - ----- -------- -- ----- - -------- ------------------------- --------- ---------- ------------------------------------ <br /> FINAL INSPECTIZYN- Date_--------- ------------ <br /> -- ---------------- <br /> - - --- - ----- --- -.... .... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F.P.00. <br /> j <br />