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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Dupficate) <br /> Date Issued ---- <br /> CIO <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 CounfyOrdinance No. 549. 6'40,n31/ <br /> - ---------- <br /> JOB ADDRESS AND LOCATIO -- - - ------- ------ ------ - - -------- <br /> Owner's Nam -- ----- _- A-w --- -- ------- Phon <br /> ------- --- --------- <br /> Address------- ---------------------- -------------------------- ----------------- <br /> me - ----- -- -------- -- -- - ---- -- -------- (--------- Phone <br /> Contractor's - I <br /> Installation will serve: Residence Apa ment House E] Commercial E] Trailer ourt E] Motel 0 Other [I <br /> Y' <br /> Number of living units: 'f <br /> Number of bedrooms �?� Number of baths/,4.P-Lot size ------------------------ <br /> Water Supply: Public system El Commurfity system El Private P(Depth to Wafer Table�--�ft. <br /> C racter of soil to a depth of 3 fee+: Sand E] Gravel 0 Sandy Loam El Clay Loam [] Clay ❑ Adobe❑ Hardpan <br /> Previous Application Made. Yes E] No New Construction: Yes X No ❑ FHA/VA: Yes ❑ Noj?K <br /> A- <br /> TYP5—Orl NSTALLAT IOWAN D'SPEJC-IFICATIONS7-­� <br /> Name <br /> —(No.septic fank.pr'cessppol permitted if public sewer_is availa-61e,within.200,fee+..) <br /> pfic Tank: Distance from nearest well-----------------Distance from foundation_________________Material_________ __-.___-____._.. - .-. _____. <br /> 0 <br /> aterial------------------------------------------------- <br /> Cj I ,., No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal d. Distance from nearest well-_____._.____.-_Distance from foundation-------------------Distance to nearest lot line_______________-_ <br /> V -- <br /> Number of lines--------------------- - -----------Length of each line------------------------------Width of trench-----------------_----------- ---- <br /> Type of filter material-------------------------Depth of filter material--------------____-- e-Total length---------------------_-------------------- pC' <br /> ��"page Pit: Distance to nearest well--A&1?--------Distance from fflundatione. istance to nearest lot line-___-------- ---- <br /> xl� 111 <br /> 'I-Rr Number of pits-------/-------------Lining ------Size: Dia/efer. ---`_---------Depth-----.r------%v­ A,- <br /> Cesspool: Distance from nearest well------------- ---Distance from foundation--------------------Lining materiidl-----------_"-I-____________.___-____ <br /> ❑ Size: <br /> ------------------------------ <br /> Size: Diameter------------------ --------------------Depth---------------------------------------------------Liquid Capacity-------------`----------------gals. <br /> I <br /> Privy; Distance from nearest well-------------------------------------------------Distance fror�,nearesf bui�cling----------------- ----------------------❑ - <br /> iI ---------------- <br /> ----------------- ----------------------------------------------------- <br /> Distance to nearest lot line----------------- ------------------------------------- <br /> ........... ------ --- -- ---- --- <br /> Remod h i-d/ r,-r.epair;ng (clescribe):-- !�e..... - -- ------- ------- <br /> - ---------------------------- ------- - -------------- --------------- -------------------------------------- -- ---------------- <br /> e o ---------- ------------- -------------- --- <br /> I "— .f --------------------r------11-------------------- <br /> --------------------- ---------------------------------- ------------------------------------------------------------------------------------------ f .� I' <br /> ----------- -------------------------------------------------------- <br /> ------------- ---------------- --­------------ <br /> ---------------------- <br /> -- � - <br /> - -------------------------------------------------- ------------------------ <br /> 27 1 hereby certify that I have prepared this applicafitin—and1 will-b-e--d-on-a-irt-actotdanc6-w-ifh San Joaquin County, <br /> f <br /> ordinances St laws, A ules and reg ations of th an Jo quln Lo I Health District. <br /> - ----- ---------- -- -- ------------- ------------(Ow ne d/or Contractor) <br /> (Signed} <br /> By----------------- -- ---- --- ------------------------------- -------------{Title --"rte------- -------- -- ------ --------------- <br /> (Plot plan',-showing'si, e of I oca-i--n -f system in relatio'n- too-wells, buildings, etc., can be placed on revers; ide). <br /> FOR DEPAR I TMENT USE ONLY <br /> ­f- --------------------------------- <br /> `-APPLICATION ACCEPTED By Z-4�1 - DATE-�--F--��e-J -- <br /> ------ ------------------------------------------------------ <br /> ------------------------------------------------------------ <br /> REVIEWED BY----------------------------------------------------------------------------------------------------------------------------- DATE ­ 4 <br /> BUILDINGPERMIT ISSUED----------------- --------------------------- ---- ------------- -- D TI ------- ---------- <br /> , 4, <br /> ---------- <br /> ---�-Xm, <br /> Alterations and/or recommendations:-_ ----------- <br /> ---------- ---------- <br /> ----------- --------------------t------ ------------ --------------------------------------------------------------------------------- ---------- <br /> -------------------------- <br /> -------------------------------------------------------------------- <br /> LW <br /> ------------------------------------------------------------------------------------------------------------I----------------------------------------------------------------------------------------------------------- <br /> Ilk- --------------------------------------------------------------------------- <br /> --------------------------- - --------------------------------------------------- <br /> -------------------------------------------------------------� 7f------------- ------------------------------------ <br /> FINAL INSPECTION BY:..."A/�, ----------------------------------- Date­rxJ <br /> - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American\rstr. 1 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-11-21x1 , Revised 1.57 F-?.CO- <br />