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FOR OFFICE USE: <br /> r r__7 <br /> ----------- -- ------------------- -------------- <br /> ------------------------------------------ -- ......... 46PPL16ATION FOR SANITATION PERMIT Permit No. <br /> -------------------------------------------------------- (Complete in Duplicate) Date Issued <br /> ----------- --------------------------------- -------------- This Permit Expires I Year From Date Issued <br /> ► D-55-Cyn .-fo <br /> Application is hereby made to the Sin Joaquin Local Health District for a permit to construct and-install-the work here-in described. <br /> This application is made in compliance with County Ordinance No. 549. f Y-T 6Al- <br /> JOB ADDRESS AND CATION .._ .1- ' <br /> Owner's Name -- ---- -- ------ <br /> --------------------------------- --------------------- ---------- Ph on -----------------------=------- <br /> Address <br /> ------1---------------------- <br /> Address......... - -- ---- --- - - ------ <br /> ---- -- ------------------------I------ -----------`j ---- ------------- ------------------------------------- ---------- <br /> Contractor's Name--- --- -- -- ------- - -- ---------------------- ------------------- -------------- Phone-----•---------------------------- <br /> lnsfallaf;on will serve: Residence [7( Apartment House El Commercial ❑ Trailer Court E] Motel E] Other <br /> Number of living units: /.---- Number of bedrooms er_o7'_Numbbaths --- Lot size ---- - ------- ---------- -- <br /> --- ---------------- <br /> [] <br /> Water Supply: Public system ❑ Community system E] Private ��Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: � Sand E] Gravel [] Sandy Loam E] Clay Loam [] Clay ��Adobe E] I Hardpan I-] <br /> Previous Application Made: (If yes,date--------- ----------) No E] New Construction: Yes El No El FHA/VA- Yes F] No ❑ <br /> TYPE:'OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Xnk: Distance from nearest well----�'.-4-------Distance from foundation-------6--------- Maferial-------------------------------------------- ---- <br /> No. of compartm-enfs-,...2�—-------------Size---- Liquid depjh-----y----/--------.._.Capacity__,F,.6_,g_. 4- -Ir <br /> -- <br /> Dis ield: Dis'fancefrom nearest well----50,!.-Distance from foundation... .-.Distance to nearest lot linej ------------ <br /> Pr <br /> Number-of lines_ .__.j__ -------Length of each line___-- ----------I .Width of trench...--2��_ <br /> Type of filter materia L -----;Depth of filter material-.--- length-------A---32'--------=---------- <br /> Seepage <br /> ength-------A---32'------------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line--_--_---------- 0 <br /> El Number of pits.`}----=---------.--.-Lining material-----------------------.Size: Diameter---------------------- Dept h---------------------- --------- <br /> Cesspool: Distance from nearest well---------- ----Distance from foundation---_-------------- Lining material...-....----------..._..------_..-._. �� <br /> ❑ <br /> aterial------------------------------------- <br /> El Size: Diameter `.-I---------------------------------Depth---- : ----:---------------------------------------Liquid Capacity-- --------------------------gals. <br /> Privy: D! ea <br /> 'stance from nrest well-----------------_ -- <br /> ------------------- ---------Distance from.nearest building............_--..--_-.-_-.-__._-_-.--. <br /> F1Distance to nearest ]of line----- ----------------------------------------------------------------I-------------------- -------------------------------------------- <br /> Remodeling and/of repairing (clesc�riibe <br /> --- -------- <br /> ...................--------- -------i----------------------oe-1 -------------- <br /> V------z7---- -----------11----------------------------------------------------1--------------------------------------------------- <br /> ------------------7-----------------------------------------------------------------------•-------------- -------- <br /> ------------------- ------- ---------------------------------------------------------- ------ ------ ----------------­------------------------------------------------------------------------ --------- <br /> I hereby certify that I have prepared this application and that the work will be done'in accordance with San Joaquin Countyl, <br /> ordinances, State 1, ., and rules and regulations of the San J;aquin Local Health District. <br /> {Signed)----------- --------------------------- ------ ----------------------------------------- ------------------- nd/or Contractor) <br /> --- <br /> . ................ .. . <br /> -------- ------- <br /> By:-------- - - - -- --------------------------------(Title)------- ------ ----------------- ------ <br /> (Plot plan, showing si'6 bf lot,.Iocationof-s to lation,t 'we s,. uildings, etc., can be placed on reverse side). <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- ------------ ---------------------------------------------- DATE------- --- <br /> ----- <br /> -------- ........... <br /> REVIEWEDBY--------------------------- -------------- - --------- ---------- --------------------------------------------------------- DATE-----------------------------------... ---------'._-•---- ' <br /> BUILDING <br /> ATE------------------------------------------------ <br /> BUILDING PERMIT ------------------------------------ --------------------------------------- DATE--------------------------- ----------------- ' <br /> Alterations and/or recommendations:..- -------------- -------------------------------------------I�T. <br /> --------------- --------- <br /> -- ---------------------- <br /> ------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------- ----------------------------:------------- <br /> -------- -------------- ---------- -------------------- -- --------------------------------- ------ ------------------------------------------------------------------------------ ----------------------------f------------ <br /> ---------­----- ------------ ---------------------------------------------------------------------------------- ------------------------ ------------------------------•--------------- --------------------- ------ <br /> . t , j, <br /> ------------- ------------------------------ ---------------------------- ------ ---------------------------a------------------------------------------------------------------------------ -------------------------------- <br /> t I <br /> k <br /> FINAL INSPECTION BY:;�---- ------------------- Date.....b <br /> ----- ---------------- ------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxelton 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 8-69 31M 3-'63 F.P.CD. <br /> /4 <br />