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FOR OFFICE USE: <br /> -------------------- <br /> I <br /> 3 a crud 3 APPLICATION FOR SANITATION PERMIT Permit No. .,� - __. <br /> - --- -------- <br /> --------------- (Complete in Duplicate) <br /> ____________________ I 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 in compliance with County Ordinance No. 549. <br /> JOB ,ADDRESS AND LOCATION.----�-Vffi 0x ' d -------------------------------------------- - <br /> Owners Name---.- h4.C-X-----------..dam . -----'-------------------•--•-------------- -- - - ----•------ Phone.----------•-•-•---------------- <br /> 4 <br /> Address P-`J1 !Q ' w-a �.a--- e 4.�--------------------------------------------------- <br /> 1 Ie 'r1� <br /> k o — <br /> Contractor's Name -... Phone....= YeS--Z <br /> Installation will serve: Residence 2-` Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑{ Other ❑ <br /> Number of living units: J____ Number of bedrooms _Z__ Number of baths ---L--- Lot size --------- --'______________ <br /> Water Supply: Publics stem Comrhonit system Private Depth to Water Table _$ �ft. <br /> PPY� Y Cry- � Y Y ❑ ❑ P <br /> Character of sod`to a depth'of 3 feet: Sand 0—Gravel D--Sandy Loam ❑-,•Clay Loam E]-Clay a Adobe❑ Hardpan ❑ <br /> F <br /> Previous Application Made: (If yes,dote---------------------) No [a- New Construction: Yes [3— No ElFHA/VA: Yes [INo <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 well_________________Distance from foundation------._..._.__._--.Material___---.._-___---______-______________._----_-_... <br /> ❑ No. of compartments--------------------------Size-----•-- --•--------•-- ---Liquid depth--------------------------Capacity--•-------------------- <br /> Disposal Field: Distance from nearlst well-________________Distance from foundation..........___.......Distance to nearest lot line_________________ , <br /> ❑ Number of lines-----I----------------------------Length of each line--------------------.-----.---Width of trench-----------•---..------------------ <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length_______.________-:.-_--_.-__•__--__---____ <br /> i!""--► <br /> Seep ge Pit: Distance to neares# well___100--_____.__Distance from foundation----Zlf...........Distance to nearest lot line--�_____________ <br /> Number of pits---. ---------Lining material----R-p-c-A----Size: Diameter____x,3_�e..��-_____Depth......Z4. <br /> Cess ool: Distance from ne�'es well_____---____-_-_Distance from foundation--------------:----.Lining material-------__.__.--.-------___-___-._._._. <br /> ❑ Size: Diameter------------- ------------------------Depth----•----------------------•------------------------Liquid Capacity----------------------------gals. <br /> Privy:( Distance from nearest well-------------------------------------------------Distance from nearest building.____________-____________.___._______.._. <br /> j] X Dista cna a to'riearest lot"lino------------------------------------- ----------------------------------- -------•--•---•------••------------------------------------ <br /> Remodeling and/or repairing (describe):_------------------------------------------•---•-------- --------- ------­----------------•--------•--------------•--._....------------------------ <br /> I e M I <br /> ---------------------------------------------------------•------------....---------------------------------------------------------------------------------------------------....---------------------------------------- <br /> ' --------' ------ <br /> Lii pfl. <br /> I hereby certify that I have prepared this•application and that the work will bedone.irf-accordance with San Joaquin County <br /> ordinances, State laws and rules and regulationsjof fhe San"Joaquin Local Health DisfricP <br /> (Signed)-------•----- -'``'" _ ---(Owner and/or Contractor) <br /> Plot Ian, showing size of let, location of system in rela4io to wells, buildings, <br /> ---------(rtle)__.__________________________.._-__.__..___----..._.____....__- <br /> 8 By:--------- <br /> ( p g y ings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 13Y--- DATE' <br /> REVIEWEDBY = ------------------------------------------- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT'ISSUED------------------------------------------------------------•--------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations:-------------------------------------------------•....... ---------------------------------.--.------••------••-----••---•------------------------------------- <br /> -! �� ----------------•-------••----------•-------------------------------------- -------------------•----•------.._._----•----- ----•------------ -----. _ .__ <br /> -------------------------------------------------------- <br /> e - - • --------------------------------- .............-.......---•------ • -----------•----------------------- <br /> -------- --------------------- -------------------------•-------------- ------------------------- - <br /> FINAL INSPECTION'BY.:: - ~ - - = ----- ��'Date .3p r< , <br /> SAJOAQUIN LOCAL'HEALTH DISTRICT-� 3. <br /> i <br /> 130 South American Street w`. X300 West Oak Street 124 Sycamore Street 205 West 9th Street <br />` Stockton,California tto"di,California Manteca,California Tracy,California <br /> EH-9 REVI6E0 8.59 F.P.00.YM 6.60 - <br />