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FOR OFFICeUSE _ <br /> --------------------------------------------------------- <br /> _____________________ ________ ____________________ APPLICATION FOR SANITATION PERMIT Permit No. ..I-Y��- <br /> --- --- ------- (Complete in Duplicate) d �' <br /> -------------- ----------- __- ------- This Permit Expires 1 Year From Date Issued <br /> Date Issued <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 /> 1- <br /> JOB ADDRESS AND LOCATION = N...4' yf �1. A�fS ( e a ------------ <br /> Owner's `...----�I-VAf ...13..1._., ig Al------------------ ------------------------------------------- Phone.................................... <br /> Address ---!X/-_./.�-- � ----------------------------------------------------- --------------------------•---------------------------- ----•---....................... <br /> Contractor's Namq.-' ly-------------/-W'A."p-------------------------------------•--- Phone-- <br /> Installation will serve: Residefice 2--"'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living unitsz.1--- Number of bedrooms .__'. Number o baths Y� Lot size . _._�'- FAC�-t� <br /> Water Supply: Public system ❑ Community sy sm ❑ Private Number <br /> to Water Table �- ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel ❑ Sa dy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No gNew Construction: Yes �o ❑ FHA/VA: Yes ❑ No [T�` <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: W <br /> No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: p Distance from nearest well-�p. Distance from foundation__�P--....-_.MaterlaL..G'ON�h��r�. '--------------- <br /> ❑ No. of compartments___._.;7�--------Size..Ak.._/,;?7-------,...Liquid depth---- _-._.--__....-Capacity_-/-1-�'.�..-_. <br /> Disposal Field: Distance from nearest well_-.. -----Distance from foundation..InC---._-_.Distance to nearest lot line..�„��..._. <br /> Number of lines----------- Length of each line_fl .��.- - Width of trench_ <br /> ❑ of filter material__� c_------------------- <br /> Depth of filter material te=e -Total length_._-.....__. LP----------------------- <br /> Type <br /> p /4------ <br /> Seepage Pit: Distance to nearest well...................__Distance from foundation--------------------Distance to nearest lot line_.._._......._.- <br /> ❑ Number of pits----------------------Lining—material-----------------------Size: Diameter--------------.-------.Depth.-------------------------------- <br /> Cesspool: Distance from nearE�si'well------- . __IDistance from foundation_._...............Lining material-------------...___.._..._.._.__._-.. <br /> i <br /> ❑ Size: Diameter----------------------------- ------Depth----------------------------------------------------Liquid Capacity.--------------------------gals. J <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 /> I hereby certify tho I have prepared this application and that the work wilt'be done in accordance with San Joaquin County <br /> ordinances, State aws nd rule nd regulations of the San Joaquin Local Health District. <br /> -7 ---------- --------------------(Signed Owner and/or Contractor <br /> By:-\............. ----------------------------------------------------------------------------------------------------------(Title)--- <br /> - - - - - -------------------- <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----------l---f-R--O--------------------------------------------------------------------- DATE---- ----------------- <br /> REVIEWEDBY------------- ------------------------------------------------------ ---------• -----------------------------------------•--- DATE------------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------ ------------------------------ <br /> Alterations and/or recommendations--------------- ------- ---------------------------------------------------------------------------------------•-•--------------------------------------------- <br /> -------------------------------------------- -------------------------------------------------------- ------------------------------------------------------------------ -•-----------------------.......................... <br /> -------------------------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------- <br /> ............._-------------- -------------- ------ <br /> FINAL INS N B : .. . .. - -- -- Date.-------- /../ -------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Na:elton 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 S-S9 3M 3-'63 F.P.CD. <br />