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V�} FO SE: <br /> A/A2-L/------------ l ------ <br /> --------------------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. .../ <br /> ---------------------------- ----------- -------------- (Complete in Duplicate) z <br /> Date Issued ____ <br /> --._____.___ This Permit Expires 1 Year From Date Issued . ._6. <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-----------t13 `n�-- _-----6_1--------���l-3��.j------------------------------------•---------------------------------- <br /> Owner's Name------- -•----• . • --••-•-- ---------1 *rr Phone.'f. 2 <br /> Address.......................... ..... ---•-------------------------------------------------------------------------------------------------------------------------...-------•---•------------ <br /> Contractor's Name.-----------feA ..........!i. _---_---------------------------------------------------------------------•--- Phone-�k�_ <br /> Installation will serve: Residence fo Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___I____ Number of bedrooms __Y Number of baths ---I---- Lot size _-___'1_ --------- ___ .co.-------_________________ <br /> Water Supply: Public system N 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® Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No [X New Construction: Yes ❑ No A FHA/VA: Yes ❑ No)� <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 depth--------------------------Capacity--•------------------•- <br /> Disposal Field: Distance from nearest well__ \.<!' 3-Distance from foundation-_____&J- ?.'....Distance to nearest lot line._Ac'..... <br /> Number of lines______--_...I_____________________Length of each line----------- -'___._...___.Width of trench---------?:7 _._-__--_-_.. <br /> Type of filter material.._S__ _ __Depth of filter material_______-X .........Total length-------------------Z 5............... <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line---_----------_ S <br /> ❑ Number of pits.--.------- -----Lining material-------------------._..Size: Diameter------------------------Depth_______-_.__-__-_-___-__-_--_____ <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material__-.____---_-.-____.-_-_-______-_-_-_. <br /> ❑ Size: Diameter--------•--•--------------------------Depth-----------------•----------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well--------------------------------------_----------Distance from nearest building.-_---__-__-_---_-----_-_..__--__---.-. <br /> ❑ Distance to nearest lot line----------------------------------------•-------------------------•-----------------• •--------------------------- <br /> Remodeling and/or repairing (describe):--------v -``---- ----- a------Q' ^"---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> l� <br /> A <br /> -----------------•--------•-----------•---------------------------•------•---------------.................................--------•----------•-------------------•-•-----------------•---•---------------------------- 4— <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)--_---------------------� ---,-------- ---------- ---------------------------------------------------------------------------Owner and/or Contractor) <br /> By:-------------------------Q-4, ------.Ctl .... } ------------------------------------------------(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 ON Y <br /> APPLICATION ACCEPTED BY-------------------------------- -_ _____ �G_.... DATE__ <br /> REVIEWEDBY---------------------------------------------------------------------------------------------------___ __ ___-•---._...--- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------- ------------------------ <br /> and/or recommendations--------------- ------- ---------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------••----------------------••-----•-------•---- <br /> -------------------------------------------------------- --------------------------------------------.---------------------------------------------------------------------------------------------------------------------- <br /> --------------------•---- --------- -- ------.. -------------------- --------------. --------------- -------------------- ---------------------------------------------------------- <br /> --------- ---------------------------- <br /> 47 <br /> FINAL INSPECTION BY:-------- -44.e---------------------------------- Date--.-.----------'/ ------- ------------------------- <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 /> ES 9 REVISED 8-59 3M 3-'63 F.P.CD. <br />