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R OFFICE USE I U-Z <br /> Permit No._T_�La- 6.- <br /> TION PERMIT <br /> - --------- -------- APPLICATION FOR SANITATION <br /> --------- (Complete in Duplicate) Date Issued <br />------------------------------------------------ -- -------- <br /> -------------------- ------I------------- -------- IThis Permit Expires I Year From Date Issued <br /> Application is hereby made to the San I Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance'wifh County Ordinance No: 549. <br /> 4 1 <br /> - TON ---------------------------------------------------------------------------------------------------------- <br /> JOB ADDRESS AND LOA ATION <br /> Name----- ----------------------- Phone-----•----------------------------- <br /> -------------I----------------------- ----------------- <br /> ---_------------- ------------------------------------------------------------------------------------------------------------------------------------- <br /> Address_ -------- <br /> Pho�e---- ......................... <br /> ------------------ ------------------------------------ ----------- <br /> Contractors Name__.------------ - -- - ------ -------------------- <br /> Installation will serve: Residence Le"Apartment House [_1 Commercial ❑ Trailer Court 0 Motel 0 Other El <br /> Number of living units. Number of bedrooms Number of baths Z.... Lot sizd-011111M---- ------------ <br /> -------------- <br /> Water Supply: Public system [Community system [1 FriVa to ❑ Depth to Wate r Table t.. <br /> 91- <br /> Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loom E] Clay Loam 0 Clay 11 Adobe Vardpan Ej <br /> Previous Application Made: (If yes,date-------------------- No 90"*".New Construciion: Yes El N0 [ZK'FHA/VA: Yes Ej No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic-tank or cesspool permitted if public sewer is available within 200 feet.) <br /> I? <br /> foundation_ --- ------------ <br /> Septic W: Distance from nearest well_________________Distance from fou on__.Zd�9........Maferi,l---�'& <br /> A A01 <br /> No. of compartments.......Z-------- ----Size___----- Liquid dep�h-------V_-01.... Capacity___",.4:::>----- <br /> nCe est lot line___-_-_____- <br /> Dis I R Id: Distance from n0irest' well_________________1Dista from foundation____--- -----------Distance to near <br /> Disposal <br /> I / line__- ----------------Width of'trench.--,;z---_--------------------- <br /> Number of lines------- - -----Leii�th of each line-- 01, <br /> ai length___- --------------------------- <br /> "Type of filter. material/tA4P406,__Depth of filter material- ------Tot <br /> 423elp Distance to nearestwell----------------------Distance from-foundation--------------------Distance to nearest lot liner_-_________-__ <br /> -------------------Lining material- --------------- Size: Diameter--- ---------------t_-_.Depfh-------------------------------- <br /> _� <br /> 1 � Number of pits_ l t1t. <br /> Cesspool: Distance from nearest weU-__:_____-1-__-----Distance from foundation--------------------Lining material--------------------------- <br /> ❑ L ---------------------------- <br /> Size: Diameter_----------------------------- ----Depth,- -- --------------!­7-------- ----------------------Liquid Capacity gals. <br /> ,�uilding' ------------------------------------------- <br /> Privy:' Distance from nearest well-______-`___-_----------- ---------------------�Disf&-nce from nearest <br /> Distance to nearest lot'line--- -------- - --------------------i--------------------------------------------- <br /> ------------------ ------------------- <br /> i ----------------- <br /> �% .._ <br /> Remodelinq and/or rep'a -----------1) <br /> rin (describe)-: -4�_ ZA'AP/ <br /> _a - .I --------------------------- -------------------------------------------- ---- -------- --- --- - ---- ----------------- <br /> 7 0 <br /> .. ... --------- ...... - -------------------- <br /> ------------------------ - --------- <br /> --------------------- <br /> --------------------------­--- •---------- ---------------------------------------- <br /> --------------------------------------------------- --------------------------------- ---- ----------------- <br /> 1,here6y certify that I have-pre�ar6d this application and thallhe 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 /> /-Or Contractor) <br /> (Signed) ------------------------------------------------------------- <br /> By---------•--------------------------------- --- ------------------;--------------(Title)- ----------- -- <br /> - ---------------- <br /> (Plot plan, showing size of lot,,Ioca+ion oi?, 0emn in relation to wells, buildings, etc.,'can be placed on'rever,so side). <br /> 4 FOR REPnT USE ONLY <br /> _YENT <br /> -------------- DATE------ ------------------------- <br /> APPLICATION ACCEPTED B --- ------ -------- - -- ---- ---- --- ------- <br /> ------------ DATE.... ----'`='-------------------- <br /> REVIEWEDBY------------------------------------- - -- ------- -----I--------------------------------------------- ------- _:---------- <br /> BUILDING-PERMIT ISSUED------- !-------•--------..--•------. -------:------------------- -------------- --------- DATE-----------------------------------------------------I--------- <br /> Alterations and/or recommend aiti.ons: ------------------- -------------.:-- �-----------_--------------------------------------------------------------------------------------------------- <br /> ---------------------------------- ------------------------------------------- -------------------- - ------------------------------------------------------------------------------ ---------------------------------------- <br /> ------------------------:---------------------------- -- ------------------------------------------------------------------- ----------------- <br /> ----------- ----------------------------------........................ <br /> APPLICATION ACCEPTED B --- -- --- -- ------ -- --- - -- - ------ --- ----------------------- - <br /> Y ---------- <br /> ........ ---------- -------------- ----------- ------ ------- <br /> �ED B ... . ........ <br /> ------------------------------------------------------------------------------------------------- --------------------------------- <br /> ----------------------------------------7------------------------ <br /> I -- --------------- ---------------------------------------------------------------- -------------------I----- -------------------------------- <br /> -----------------I------------------- -------------------------------- ---- <br /> ----------------------------------- <br /> Date------ <br /> FINAL INSPECTION BY. .............. ----- ---- - I <br /> ------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> ti <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES-9 RMSED 6-59 F,FX13-ZM 6-60 <br />