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FOR OFFICE USE: <br /> ---------------------------------------------- � .. _ . <br /> ........................................ APPLICATION FOR SANITATION PERMIT Permit No. __ " ._ .. <br /> ........................................................... (Complefe in Duplicate} _ <br /> - ............. This Permit Expires 1 Year From Date Issued G�� Date Issued �Q.--/-. mss <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. 0 2ct0 6,0 <br /> JOB ADDRESS AND /LOCATION <br /> `-?'n_6 <br /> -4vt-- ....... <br /> Owner's Name - f l�+• ^... ---� - ---!----- <br /> _------•------------------------- . ..-----------•--•---•------.._... Phone---...........-----............. <br /> Address--------- 1...�`�r¢_-_�----- .. <br /> Contractor's Name...---&"4.;w.... .1-....................................................................... Phone-•-------------------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑/ <br /> Number of living units: -------- Number of bedrooms _-. Number of baths Lot size <br /> Water Supply: Public system ❑ Community system ❑ Private e Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy.Loam [BClay Loam ❑ Clay ❑ Adobe❑ Hardpan [❑ <br /> Previous Application Made: (If yes,date....................I No ❑ —New Construction: Yes ❑ 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.) 7�- _ <br /> Septic nk: Distance from nearest well....-Rq� :t Dista`�e fro foundation.....'' �__.... Material.... :?��- _.-_._ <br /> P --------- u �, ..�Liquid depth-----0`----....... . Capacity---Fo!J <br /> No. of com artmonts....._ -SiSize__ __ _.. ..-- <br /> Dispose field: Distance from nearest wefl____��d.;.._Distance from foundation_-..f.tt----___._Distance to nearest lot lines ...... _ <br /> Number of lines.......CA........ ..........Length of each line------ ......._.Width of trench_.-Z__ _,.._._______..... <br /> Type of filter material--- ....Depth of filter material -./_.9____--_---.Total length_..�b..Q ..:...............!...__ �► <br /> Seepage Pit: Distance to nearest well... ...............Distance from foundation......_._______.._Distance to nearest lot line---------- <br /> ❑ Number of pits--------------------_Lining material........................Size: Diameter....:.... - .......Depth......................... <br /> . � O <br /> Cesspool: Distance from nearest well.................Distance from foundation........____... Lining material........ ...................__._=G� <br /> a te <br /> ❑ --- <br /> Size: Diameter------------- -- -------------------Depth-.... -...-------------------- ...................Liquid CpacitY-•------------------:-._....gals.- <br /> ry <br /> Privy: Distance from nearest well......... --- ..-........... .........Distance from nearest building.....___-___-._-_-__--.._. . . <br /> ❑ Distance to nearest lot line -----------------------------------------------------------------..-......__........._------------------------------- <br /> ,E <br /> ',rte•• <br /> Remodelingand/or repairing (describe)--------- - --------- ....... - ----••-•-••--------------- ------•------------- ----- _. - ----- -------_---•-------•------- .r <br /> ---------------------------•-------------------------------•------. --•- ------ --------..-.-------------------------------------------... .. --- ------...-•---------------------..........._...__. . .. <br /> .r <br /> -------------------------------------- --•--•-••••--------------------•-----•----- . <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances. State s, and rules and regulations of the San Joaquin Local Health District. <br /> Si ned .. -------------- ...... . ... and/or Contractor <br /> (Signed) / ) <br /> By... � :.. ------ ----. .trl!1- :..-.(Title) ...- <br /> (Plot plan, showing size of lot, location of system in rely n to wells, buildings, etc., can be placed on reverse side). I , <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.... ,( . ----------- - -------------- DATE.---Q _...._._.. <br /> REVIEWED BY---------W-.P ---------- ------ -- DATE. ../ _.'/.._:. ............................... <br /> BUILDING PERMIT ISSUED----------- -------- -.... --------- DATE----------------------_..._..- -----_... .........-•---- <br /> _ ..,_ .._ .�_ �..� <br /> Alterations and•/or recommendations:...................... _ <br /> . . ................--------------------------------------............ ... •---.........--- -- ------.....__...-----------.....--------------......------..._.... . .. .................................................... <br /> -------------- - -- . ............ •-•--• ........ . .- ................................................:................................................... ...........................-...... <br /> -----------------------------•------ ...... ------------------------------------................................................. .......................................................... <br /> .. . <br /> ......................................... .. ....... .............................................................. _.. -. .. .... ....................................................................... <br /> FINAL INSPECTION BY:.... ..._ Date_...!--. .�. .�.t1. -..... ........................ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Ha=elton Ave. 300 West Oak Sheet 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,Colifomia Tracy,California <br /> ES 9 REVIBEO B-59 3M 3•'63 F.P.CO- <br />