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FOR OFFICE USE: I <br />----- ---------------------------------------------7----- -- PERMIT Permit No. <br /> APPLICATION FOR SANITATION <br />...... . --------------------------------------­ (Complete in Duplicate) Date issued ---- <br />----------------- <br /> ---------------- -------- ------------ -------- - k'­vThis Permit Expires 1 Year From Date Issued &111'r <br /> ------ h <br /> Application is hereby made`oto fh-e Son Joaquin Coca! Health District for a permit to construct and install t 6 work herein described. <br /> 9 <br /> This application is made in -compliance,with County Ordinance N o._,*9 <br /> 10 --- ------- ..... <br /> JOB ADDRESS AN LOCATION.&AL-- ------- ----------- <br /> -------- Phone---- ------------------------------- <br /> ------------------- <br /> ---- ------ <br /> Owner's Name-------- --- -----0"V ----------"I <br /> ---------- ------- --------------------------------- <br /> Address * a- ----- ------------ --------------- <br /> Phone.----------- ---------------------- <br /> ----- ---------------------- ------------ <br /> -1-1 ------ --------------- <br /> 7 5 ----------- ------------------ <br /> Contractor's Name. ---- Motel Other [3 <br /> Installation will serve: [Res'idence gR-��_Apartrnent House El Commercial El Trailer Court [I El <br /> bedrooms -3-- Number of baths ---I---- Lot size -------470------------------ <br /> Number of living units; _1---- Number of be - ---------- <br /> Water Supply: Public,system E] Community system ❑ PhVate-UT__Depth to Water Table <br /> Gravel.Ef Sandy Loam 0 Cla y,coarn C] Clay PT--A�clobe 0 Hardpan 0 <br /> Character of soil to a depth of 3 feet: Sand E3 FHA/VA: Yes E] N o F& <br /> - � <br /> Previous Application Made: (if yes,clate------ ---- <br /> ) New Construction: Yes' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within.200 feet.), U'l <br /> on-------------------.Ma <br /> --------- <br /> Septic Distance from nearest well. .___-`:Distant d — ' epa_. ----------- yt� <br /> frornAujotapacTty__�_�' <br /> .4 Liquid depth--- - --------------- ---------- <br /> No. of compartments---�177�---------- --Size-----7---X-- ------- <br /> on-M!----------Distance to n.earest lot line---W521��l <br /> Disposal Id: Diitance from nearest well---�p -;,.Distance from foundation <br /> Number of lines_____=__._ each line-,/ <br /> A,? —r --V-.Width of trench <br /> Length of e ------- 5---_ - , <br /> -----Depth of filter material ..............Total Iengfh_1,Ae.-?:r—_j---------------- <br /> ate,;., <br /> Type of filter mc rial-'--/ <br /> -------------D- t c <br /> e to nearest lot line-l_____._____._._ <br /> Seepage Pit: Distance to nearest welA-oa----------=Disfa 44 <br /> — ----------- <br /> Lining material----al--- peA-Size: Diameter----- --- Depth_,-Zf_J---- <br /> Number of pifs, ------------ E <br /> -F <br /> Cesspool: 1pstance from nearest well --------------------Lining material--------------------------:----------- <br /> -----------Distance from foundation <br /> Size: _Diameter--------------------------------------Depth_----------------------------------------------------Liquid Capacity -----------gals. \A <br /> ❑ <br /> 4 --------------- <br /> Privy. Distance--from,nearest-well----___.,----_.----------- _-Distance.-from-nearest-building------------------------------------------ -- <br /> ------------------ ------------ <br /> ❑ <br /> Distance to nearest lot line------ ------------------------------------------------ -----------__--------------------- <br /> ----------------------------------- ---------------------------- --------------------- ------------ -- <br /> Remodelin4 and/or repairing (describe)--------------------------------------------------- --- --------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------­ <br /> ---------- --------------------------------------------------------------------------------------r----------------------------a-------------------------------------------------- -------------- <br /> ---------------- <br /> --------------------------------------------------------------------------- ---- --I_p1_: ------------------------------------------------ ---------------------------------------------------------------- -----------t <br /> ------------ -- -P ation and that the work will be done in accordance with San Joaquin Court y <br /> I hereby certify that I have prepared i a pp� a <br /> I I a I ions f the Sa oaquin Local Health District. <br /> ordinances, State laws, and rules and re 0 <br /> q . -------------------------------------------r--------------------.(Owner and/or Contractor) <br /> - -- -------- . ... ... <br /> (Signed_ ----- --------------- - ------ - --- <br /> -----------------------------------------(Title)------------------------- ----------- ---- --- ---------- <br /> -------------------------- <br /> -------------------- ------ ....-------------------------- -------- ---- <br /> of lot. location <br /> f <br /> 0 Sys em -buildings, etc., can be placed on-revjerse-side).— <br /> (plot plan, showing size, of,lot, location of system in re tion to wells, <br /> FOR DEPARTMENT USE ONLY <br /> ---------- <br /> APPLICATION ACCEPTED BY-------- ---------------------------------------------------------- ----- --F-__!�-/- DATE_------- <br /> REVIEWED BY------------------------------------------------------------------ ---------- ------------- -------------- ----------------- <br /> DATE-------------------------------------------------------- --- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- <br /> ---------- -—---------- <br /> Alterations and/or recommendations------------------------------------------------------------------------------------------- ------------------------- <br /> -- -----------------------------------------I--------------------------------------- —---------- ------ <br /> ----------------------- ..... <br /> ----------------------------------------------------_----:.1_1- <br /> --------------------------------------------------------------------- <br /> ------------------- -----------------------I------------------------------------------ <br /> ------------ <br /> -------- ------------------- -------------------------------------- ----------------------------------------------------------------------------------------------------------------- ------- --------------------- <br /> --------------------------- ----- ----------------------- ------------ ---------------------------------------------------------- --------------- <br /> FINAL INSPECTION BY--------/. ...... ------ --- Date--.-.-.-./--- <br /> -­---------------------------------------------------------------------------- <br /> - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave, 300 west oak street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> 9 REVISED 8-59 :3M 3-'63 F.P.120, <br />