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-_�K'OFFICE USE- �` l <br /> 2 e7n <br /> U APPLICATION FOR SANITATION PERMIT Permit No. U.r <br /> ---------- ---------------------------------------------- <br /> ------------ ---- (Complete in Duplicate) / <br /> _ . ...� —Date Issued <br /> ___________________ --------------------- -This Permit Er pires 1 Year From Date Issued' <br /> Application is hereby made to the Sen 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 /> 0"ll! <br /> JOB ADDRESS AND LOCATI N � 5_ --'�•�-- � ----•-------- <br /> P j <br />._.. Owner's.Name L!. t s--=•--------------------- -------- --V----•---- ----- Phonefo7?J �Q <br /> r <br /> Address------------------------ _ .. .> •.`-'�-' --�-!-�.-- ------ 1 f .. ---------------- -10 <br /> .. <br /> i �_ <br /> .. - T r r <br /> Contractor's Name__. _ .f:' i �.�: �` �' --••-•------. <br /> Installation will serve: Residence rr� Apartment House D Commercial ❑ Tr:ailer Court-[] Motel ❑ Other ❑ <br /> Number of living units: _ Number of bedrooms <br /> ,Number of baths . f { e <br /> g i � Lot size ---­----------------------f -•-------------------•-- <br /> Water Supply: Public systemi Community system[] Private ❑ Depth tov,Water Table ft. <br /> �* <br /> Character of soil to a depth of 3 feet::.Sand E] G4av6ll.❑n',Sandy Loam ❑ Clay Loam,❑ Clay E] Adobe ]' Hardpan ❑ <br /> Previous Application Made: Ilf yes,date__________ __} No [-O New Construction: Yes ❑ No d. 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.) - x <br /> Septic Tank: �e Distance from nearest well.:'--------------Distance from foundation___-__-_-_______-Material...------------._______-______________________._. <br /> 1" ---------Size-------1 --. Liquid de th--------------------------Capacity <br /> ❑� No. of compartments ---F� � - ----------------- a p. ------------•------•--- <br /> Disposal Field: Distance from nearest well--------":_r...._Distance`from foundation,--------------------Distance to nearest lot line----------------- <br /> ❑ t5 `1Number of lines--------------------- ----`'-_ Length of'-each'Gine------------------------------Width of trench----------------------------------- <br /> Type of filter material----- Y- -�;-Depfh:o•f-�filter material-----------------------Total length------------------------------------------ <br /> _T <br /> ------ ------------------- <br /> 5eepage Pit: Distance to nearest well-------- fromrfoundation_-foundation ---rDistap'ce to nearest lot line-_/0______- <br /> 1 jF----Lining material- � :__---Size: Diameter.__r__�-------------Depth_t_ ---- rr <br /> 0. <br /> Number of pits � .._ �� � ---••-•--------� W <br /> Cesspool: Distance from nearest well__________ ____ _Distance'fr17*b'mJoundation_-----------_____-_Lini id material <br /> at ecit ale. <br /> ❑ 5izeaDiameter----------�------------------------------- ----- _iDepth--�� [ 'Y .---. q 9---•y�----------------------------------- <br /> :4F <br /> ---- ------------------- -g----- <br /> Privy: Distance from nearest well -- --- Distance from nearest building <br /> �.. . F k .�I ? _,r -.tea.— i� <br /> ❑ Distance to nearest'I t line----------------------------------------------------•---•-=----------- ---------------------------------------------------------------------- <br /> IRemodeling and/or repairing (describe): ---------�� `3 <br /> = ----------------- _ -f` 4Q�? _ _ _ ,r _---1�----.t��' <br /> --••------------ - <br /> (�, . --------------------------------- <br /> ------------------ <br /> -- --.-•------------------- <br /> ` ..` -----�=t=--==------------------•---------------- <br /> --------------------------------- <br /> I hereby certify that I have prepared this application nd that the work wilt be done in accordance with San Joaquin County <br /> ordinances, State laws, and ruies"nuc-regulations of the San Joaquin Local Health District. ,. <br /> } 1 t <br /> 1 ----------- <br /> (Signed)_-- .S ` �'° ------,-•-----/-/?- _____------ -,----(Owner and/or Contractors <br /> BY .. } = - = J''?cL {Title) - -`-------------- , <br /> (Plot plan, showing size of lot; location of system in relation,to wells, buildings, etc., can be placed on reverse side). <br /> _ - - r <br /> i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------ ------ -V____ r ---------------------------------------------------- DATE------ 1---------------------- <br /> REViEWED BY ------------- -4-------- ;mea ` *= DATE <br /> BUILDING.PERMIT ISSUED--- ------------ ----------..:_.-------•-- - -----------------------I----•--- <br /> D <br /> ATE--------------------•---•----------- •-------------------- <br /> Alte�r/a/}/yand/o recommenda -------------- ----- ---— ------------•---------•--•--.....-----•- --• <br /> $ -. - <br /> R <br /> ____________________________________._._--___.._-._____.__.______.__-_____._.______._._____.___.;-----__-_--------------------------------------------------------- ------------...-------.-... ------ _._.____.._. <br /> FINAL INSPECTION BY: /. / -- ------------ Date----- -- �--•--- ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <br /> 130 South American Street 300 West Oak Street 114 Sycamore Street 205 West 9th Street t <br /> Stockton,California Lodi,California Manteca,California Tracy,California f <br /> ES-9 REVILED 8-59 F.P.GO,ZM 6.6D ! i <br />