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FOR OFFICE USE: ST <br /> APPLICATION FCR7SANITATION PERMIT Permit No. <br /> -- . �-- <br /> f <br /> ------------ ------------------------- - ----- ---- -- (Complete in Duplicate) q <br /> ------------ This Permit Expires 1 Year From Date Issued Date Issued <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 incs mplionce wit County Ordinance No. 549. <br /> JOB ADDRESS AND O TI N_ ___-_-- �"S_. !_�,--!_"T-�-�-- ----- -- - - <br /> Owner's Name---------- -- --•- =------ ' Phone <br /> -------- <br /> Address-------------------------------- ------�--- -:--.--------- v`a--------------------•------------------------------- <br /> Contractor's Name------------- ---- -------- -------------- ---------:--------------------. Phone--------------------__- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units:-_t------ Number of bedrooms ___S_ Number of baths ___1yCot size ---------- ______._`__________________________ <br /> Wafer Supply: Public system ❑ Community system ❑ Private Depth to Water Table ..._ __ ft. <br /> Character of soil to a depth of 3 feet: Sand r Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0 Hardpan ❑ <br /> Previous Application Made: (If yes,date____________________) NoY New Construction: Yes$t No ❑ 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.) <br /> Septjp T k:� Distance from nearest well__t_Q_o_ _-Distance from foundation-___3__C?---------Majerial----q. ------- --------------------- <br /> No, of compartments-------- -------------Size--- ----------.Liquid depth-----4--/-"�-'.--------Capacity----- 4?_p_------- <br /> isposal Field- Distance from nearest well__-/6*47Fisfance,from foundatio ___..3 (stance to nearest lot lin <br /> Number of lines___3-__._____el __________ Length of each lined ____8. '_� Width of trench:------- ______________ <br /> Type of filter material._(_ _Depfh of filter material____1__f_________Total length----__- Z �---------------- <br /> age it; Distance to nearest well----------------------Distance from foundation----------------.__.Distance to nearest lot line__________.____._ <br /> ❑ Number of pits----------------------Lining material--------------.--------Size: Diameter------------------.---Depth--------------------------------- <br /> d <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material—--_-___._------_-__________--___. <br /> ❑ Size: Diameter µ Depth_ Liquid Capacity-'----------- gals. � <br /> A t 6,�— <br /> Privy: Distance from nearest well 1---!#� '''_____--_____1___-__._Distance from nearest building____________________________________.__. <br /> El Distance fb nearest lot line-.,,. -r------------ - ------ -------- ------------------------- --------------------- <br /> ------------------------------------------------ <br /> Remodeling and/or repairing (describe) ...- L-1---------f �---------------•-----------------•-......- <br /> ----------------------r-----------------I---------------------- -------- <br /> ---------------------------1-1-------------------- <br /> -------------------------------•-•-------------------- ------------------ -•------_ = - <br /> L C <br /> -----------------------------------•-------------------------------------------------------- --------------j--------------------------------------------------------------------------------------- -------- - <br /> I hereby cerci y that I have prepared t ' pplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, St aw nd ru s an r ati s of the Sian Joaquin'Local Health District. <br /> (Signe d --------- ------------- ---------- --------------- -------------------------(Owner and/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 /> t . <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- •--------- ------------- -------------------------------------------- DATE <br /> REVIEWED BY_- ----- ------------------- ------------- DATE--- ------- <br /> BUILDING PERMIT ISSUED ------------------ DATE-------------------- ----------- --- <br /> Alterationsand/or recommendations------------------ --------------- ------------ ------------------------------------------------------•-----------------------------------------•-------------- <br /> ------------------------------------------------------------------------------------------------------------- -------------•------------ ---------------------------------------------------------------------------- <br /> ---------------- ------­---------------------- ------ ----------- ---------- ----------------------------------------------------------------------------------------------------- ------------------------------- <br /> ---------------- ------------------------------------------------------------ ----------------------------------------------------------------------------•-----------•------------------------------------------------------- <br /> ----------------- -- ------------- Date_----- - ------------------------------------------------------------------------------------------------------------------- <br /> Y <br /> .. <br /> FINAL INSPECTION BY------ -------- --------------- --------------------- ------ <br /> -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haielton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 3M 3-163 F.P.CD. • <br />