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APPLICATION FOR SANITATION PERMIT Permit No. --------- <br /> (Complete in Duplicate) Date Issued <br /> 77-4 -S.'7-: %I <br /> Applica+ion 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 LOCATIONJ -- -----------Z-3-t1­1�—­ ------------------ ---y <br /> ---- ---- --- <br /> f-.-A- A....... <br /> ---- V <br /> Owner's Name-------------------0 a �Ipr 4------------- ------- - ---- - ------ ----------- ---------------- Phone------------------------------------ <br /> el - " f" <br /> Address...................----------------------- ------------------ ----------­­------------­ <br /> -------------------------------------------- <br /> Contracfqr's Name-------•--•--••--•---------------------- --------------------------------------------------------------------------------------------- Phone------ --------------------------- <br /> Installation will serve- Residence M Apartment House E] Commercial L] Trailer Court- 0 Motel [:] Other L] <br /> Number of living units: Number of bedrooms --A-. Number of baths -4n- Lot size 7s__X./ ---------------------------- <br /> Water Supply: Public system E] Community system 171 Private E] Depth to Wafer Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam I?] Clay Loam El Clay I--] Adobe 0 Hardpan El <br /> Previous Application Made: Yes E] No El New Construction: Yes 0 No El <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 wel�_��_._.-__ <br /> - Distance from founjation-mV---------- ------------------- <br /> ----------- <br /> No. of compartments...----- Size---1AX-V-X--- ---Liquid clepth-,Z­*---------------Capacify--4Zde------- <br /> Disposal Field: Distance from nearest well--775---- Distance from foundation--.X----------Distance to nearest lot <br /> 01 <br /> F91 Number of lines------------2 A 4 -- Total -- <br /> Length of each line---:Y yo, -- --------Width of french------Aj�- -"--------------- <br /> Type of filter material- Depth of filter" m''iteri�l--- ----- ----- otal length----- 47 <br /> )� 0------------------------ <br /> - <br /> Seepage Pit: Distance to nearest well-----------------------Distance from foundation-------------------Distance to nearest lot line----------------- <br /> ❑ Number.-of pits:i--------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- <br /> 1 T <br /> Cesspool: Distance from nearest well-_-_____________Distance from foundation--------------------Lining material-____________________________________ <br /> ❑ <br /> aterial-------- ------------------------- <br /> El Size: Diameter------ ---------- - -----­----------Depth—-------------------------- ----------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well---------- --------------------------------------Distance from nearest building------------------------------------------ <br /> ElDistance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (desc 11 ribe):--------- ------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------- --------------------------------1------------------------------------------- -----------------------­­­­- <br /> ----------------------- <br /> -------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - <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:-----------=-----------•----- ----------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- <br /> _(Plot plan, showing size of lot, location of_systenjj ,.,efc., con 6e,F!,Ikeed on reverse !!4je­, <br /> kin relafionto wells, 6uildings <br /> FOR 014'ARTM qSE,?NLY <br /> APPLICATION-ACCEPTED BY-----. -- .......�­ ­DATE­4/r/,)/-�4 ---------------------------------- <br /> REVIEWEDBY-------------------------------------------- ----- -------------------------------------------------------------------------- DATE------------------------------- ---------------------------- <br /> BUILDINGPERMIT ISSUED---_..--_.. 1---------------------------------------------------------------------------------------- DATE------------------------------------------------------------ <br /> Alterations and/or recommendations:------------------ ------- - ------ - ---------------•---------=-•--•--------------------------------------------------••------•---------------- -------- <br /> --------------------- --------- $------------------------------------------------------------------------------------------------- <br /> ----------I--------------------------------------------------------- -------------------------------------------------- ------------------------------------------- ------------ ---------------------------------------- <br /> ---------------------------------------- -----•-- -------- ----- ------------------------------------- -------------:- ---------------- ------------------------------------------------------------------ ----- <br /> ----- ----- ------------------------------------------------ ------------ ---- --- ----------- --------------------------------------------- ------------- --------- ------ ----------- - --------- -------------------- <br /> FINAL INSPECTION BY:-� ---`------- --------------- Date_-- - - --- -------- --------------------------------------------- <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 /> Ii <br /> ES-9-2M 145946 A7WCOD 12-54 <br />