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FS4.'-4OFFICE USE: <br /> ----------------------- ----------- APPLICATION FOR SANITATION PERMIT Permit No. . _�� `_... I <br /> -s-- ------------ ..._------------- --- (Complete-in Duplicate) � 7 <br /> ---- - ------------ Y_-_..-_--- Issued Date Issued-- This Permit Expires 1_Year From Date 1......._..___.. <br /> Application is hereby made to the San Joaquin Local Heal}h District for a permit to construct and install the work herein described, j <br /> This application is made in compliance with County Ordinance No. 549. t <br /> JOB ADDRESS AND LOCATIONr___ �-Z �l------ <br /> _ Q � �� f <br /> Owner's Name y/ ...__ rro�<! ------------•---------------•--------------------- ----------------- ---------------- Phone----•--------------------•-----•---- <br /> Address---------- <br /> Contractor's Name-- S � - �. <br /> .. - Phone---------------•-- <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Tre er Coui•t ❑ Motel ❑ Other ❑ <br /> Number of living units: __ .Z--_ Number of bedrooms --1--- Number of batlis _�___. L t size:__` � __..'7 __ ________________________________ <br /> Water Supply: Public system Community-system ❑ Private ❑ Dep*'to Wafer Table .6G?.ff ' <br /> Character of soil to a depth of 3 feet- Sand ❑ fGrave€ ❑ Sandy Lc,am❑"Clay Loam ❑ Clay~❑ Adobe [Hardpan ❑ <br /> Previous Application Made: (If yes,dote_.----............. ) No New Construction: Yes El' No R�- FHA/VA: Yes ❑ No [ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ; <br /> (No septic tank or cesspool permitted if'public sevi;t is availa61elwithin 200 feet.) <br /> Sep4��t <br /> . Distance from nearest well----------------Distance from foundation------------------- -_-._-_________._...----.-.__-___....._.__._. <br /> No. of compartments-- - - ..Size-------------------- -----------Liquid depth -------- - ----- --------Capacity----- a <br /> Disposal ie Distance from nearest well...._~-_-.......Distance from foundation--?----------------Distance to nearest lot line.__-'V----_---- �. <br /> Number of #ines----I----------------------------Length of each line-- __-20. ------.------.Width of french-----!-!--------.-.-------- <br /> Type of filter materiel_:.___4. dC'____ ---Depth of filter material_�. -._.Total length.__.._��_---__ _______________ <br /> Seepage Pit: Disfance to nearest well---._.___ _-__Distance from foundation-.`J-_�___..__-_.Distance to nearest lot line--.1__�_____.._ <br /> Er Number of pits.-- _11_. ------------Lining material._'_+�P!-A..._ Size: Diameter---.-- 3�----__Depth__ .3_-_�. <br /> --------------- <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 /> Remodelingand/or repairing (describe):-- ----- ----- - - ------------- ------------------------------------------------------------- -----------------------•-------------------------•------ <br /> ---•--------------------•-•--•---------------------------- --------------------------------------------------------------------------------------------------------- ---------- -------------------- ----- <br /> ----- ------------------------------------ ---------•-------------------------- -----------•------------------------------------ i <br /> --------- -------------------------- -----------------------------------------------------------•------------------------------------------------------------------------------------------------------------ --- --- ----- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County r <br /> ordinances, State laws, and rulst aqd regulati ns of A San Joaquin Local Health District. <br /> F € <br /> (Signed).-------------------------------------------------- - - ----- -------------------------------------------------------------------- <br /> ---.__._... _(Owrrer—arrd/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 /> ACCEPTED BY.- _ -�.------------------- - ------------- DATE- ---------------------- <br /> APPLICATION <br /> REVIEWEDBY------------------------- --------- --------- .------------------------------- --------- --------------------------- ---- DATE i <br /> BUILDING PERMIT ISSUED-------- -- ----- ....---- .ATE------ --- <br /> Alterations an o recce ,mend tipns: <br /> -�--- - ---- -------------- - - <br /> — <br /> -------- - — - - --------- -------------------------------------- t <br /> -- ---------------------------- <br /> 15- <br /> ----------------- - ---- --- - - ------------ -- ------ - ----- ---------- f <br /> rt 3n <br /> -----------------­------- -------- - � <br /> FINAL INSPECTION BY:.- --Z'".- \1- - - ------------------- Date-- -r------�--7- <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,Corifornia Tracy,California <br /> E.N.92M 1-67 Vanguard Press <br />