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N N <br /> APPLICATION FOR SANITATION PERMIT Permit No. ./a.. <br /> (Complete in Duplicate) Date Issued <br /> t I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> his application is -made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND ATI ------------- <br /> ----- ----- --------- --- ---- ------------- ------------------------ <br /> Owner's Na e-_. ---- ------ -- ---- ---- - -------- ---- --- --- ----- ----------------- --- ---- ---- Phon ----- <br /> Addres --- --- ----•,..._j __ - - e <br /> Contractor's Name------ ----- ------------------------------------------------------------- ---------- ---------------- Phone----.... -------- <br /> Installation will serve: Residence" Apartment House E] Commercial E] Trailer Court E] Motel E] Other E] <br /> Number of living units. __.---- Number of bedrooms -2- Number of,baths.,/,,. t,size ...... ------------------------ <br /> t _�oj <br /> Water Supply: Public system E] Community <br /> 7,,nlity system ❑ Private Depth to Wafer table 7--- ft: <br /> Character of soil to a depth of 3 fee T: Sand E] Gravel El Sandy Loam Clay Loam E] Clay E]' Ad be-[]-',.Hardpan El' <br /> _0 <br /> Previous Application Made: Yes 0 1 NoY New Construction: Yes E] ,No <br /> No <br /> , FHA/VA: Yes M " <br /> TYPE:OF INSTALLATION-AND$ <br /> SPEiC I F I GATIO INS: <br /> (No septic tank or'cesspool permitted if public !s -.Is availa6le'within 200 feet.) <br /> Septic Tank: Distance from nearest well isfance from fouydafio 01_�Zlllea fp r i a I--- -------- -- ---- ------------------ <br /> �;2 Z f <br /> r r7a4�� <br /> No. of compartme6fs-_ --- ------- i L e ity---- <br /> D�wl Field: Distance from nearest we �stance from founclafio ------ ­ -.Distance fo,\n'-e f lot lin'- <br /> Number of lines_.______________----------------- ----------Length of each line_____ ------- -------------Width of trench.___.V__11....I <br /> ------------- <br /> Type of filter ma Xpri-a)--------------- ---9------Depth of filter material-----------------i_____TotaI length,_ i----------i <br /> Seepage Pit: Distance to nearest well____________---------Distance from foundation--------------------Distance to nbrel, �31—inte----------------- <br /> ❑ Number of pits--- -----------------Lining material-----------------------Size: Diameter-----------------------De ........ <br /> -- <br /> F ---- ----------------- <br /> Cesspool: Distance from'n nearest well-----------------Distance from foundation--------------------Lining material-__'__.____________-_______.________-- <br /> 0 Size., Diameter-------------------------- -----------Depth----------------------------------------------------Liquid Capac' --------------------------gals.---------- <br /> Y' <br /> L y <br /> ivy: Distance froi-6 nearest well--._1_________________________-------------------Distance from neares-f budilding-C---------------1. .0-1 <br /> ------------ <br /> El <br /> Distance to nearest lo-f,line- <br /> -------------- <br /> 9Z <br /> Remodeling and repairing (describe):--- <br /> /or ----------- — ------- -- ----- -- <br /> -- -------- -------------- ------- --- - ------------------------ <br /> • <br /> ------------- ------- <br /> ------------------- <br /> ----------------- <br /> -------------- --- -------- -------------------------- ------------------ <br /> ----------------- <br /> --- -------- - ----------------------------------------------------------------- <br /> e epare ion an that e fif that 1 111 is ,,Ir at e work wi be done in accordance wit San Joaquiri County <br /> Y c an 11 and regulations of the San Joa in Local Health District. <br /> ordinances, Stat <br /> (Sined)---------- - -- --- - ----------- - -- - ------------------------------ ------------------------- <br /> �9 - --------------------------------------- --------(Owner Contractor) <br /> By:-------------- ----------------------------------------------------------------------------------- Ifle e�=- -- --------- -- -- <br /> iej.(Plot plan, showing o lot, location I a+ion bf system in relation to wells, buildings, etc., can be pl on reverse side). <br /> -7 DEP RTMEn USE ONLY <br /> APPLICATION jACCEPTED BY <br /> -------------- DATE --------------------- <br /> REVIEWEDBY-=---------------------------------------------------- -------------I------------------------------------------------------ DATE----------------------------- ------------------------------ <br /> BUILDING PERMIT ISSUED----- ------- I --------------------- DATE <br /> ------------------------------------------------------------------ <br /> Alterations and/or recommendations:_______---.___.___ --------- -------_----------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------I---------------------------------------- --------------------------------------------I---------------------------------------------------I------------------------------- <br /> ---------- ----------------------------------------------------------------------------------------I--------------------------------------------------------------------------------_------------------------------------- <br /> 1 10 <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----- ---------- ---------------------------------------------------------------- ----- - ------ ------- --------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY 'r,t-_ Date <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 Lodi, California Manteca, California Tracy, California <br /> E5-9-2M kevisoa 1.57 FRCO' <br /> 172, <br />