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FOR OFFICE3USE: <br /> .� <br /> --------------------------------------------- ----------- APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) _ � <br /> -. _ i� Date Issued. �. <br /> = ----------------------- This Permit'Ex Tres 7 Year From bate Issued J�(Q: '� 1 <br /> 2A <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and install'the wo-rVherein described. <br /> This application is made in compliance with County Ordinance No. 549. t <br /> JOB ADDRESS AND L CAT 0� Of <br /> _ <br /> �' <br /> ---------------- -------- <br /> Owner's Name ; y=.�" <br /> s t -- - - ---- ------------ ---------------- Phone-!_._�' �Oa <br /> Address , � '12- --------••------•------------------- '= <br /> --.. <br /> Contractors Name------------------------ ---- -LL _ h ne f� <br /> I Installation will serve: Residence ❑ Apartment House ❑ commercial ❑ Trailer CourtMotel -1Other s <br /> Number of living units:.- Number of bedrooms Number of baths , Lot size ____-L�__�� _____________ ___________ <br /> Water Supply: Public system El Community system ❑ Private Depth to Water Table/fd"- tt. <br /> r <br /> F Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ San y LoamXClay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,clate--------------------) No ❑ New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE.,OF INSTALLATION AND SPECIFICATIONS:— <br /> (No <br /> PECIFICATIONS:(No septic tank or cesspoolpermitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest-well__4 _-_:Dista c; from founds ion__ - <br /> �Q-�------.Mat �ial'� ��"--------------------------------- <br /> No. <br /> of compartments------->�------------Size!%�_4X/Liquid depth----- ---------------------Capacity--07.-- �(d. <br /> Disposal Field: Distance from nearest well-4574`_tpistance from foundation-- _4)-...---�---_Q�stance to nearest lot I�f;e---- t <br /> Number offines'__--__ ___ Length of each line%�-1Qd__ UYod+7i�th of trench_.__,3_7�j-_,;____. . _ <br /> Type of filter material-Sl Depth of filter material_/$-_'_____-__-Total„length_=---------------- -- Q_-------- <br /> 1�. <br /> Seeit: Distance to nearest well----------------------Distance from founda.fion-_------_-.__-----_.Distance to nearest lot line_.--_�-_------ <br /> Number of pits---- -----------------Lining material------------------ ----Size: 'Diameter-----------------------Depth--------------_-----(---------- j <br /> . e � <br /> C sspool: Distance from nearest weil------------------Distance from foundation---------------.-.-.Lining material ------ <br /> ❑ Size: Diameter ' <br /> ----------------------------------Depth-------------------a <br /> --------------------------------Liofuid Capacity . ---gals V} <br /> Privy: a Distance from nearest well-------------------�_______.__------_-.-_---_-_- _Distance from nearer# building------------------------------------ _ r <br /> ----- ---- ----- <br /> ❑ Distance to nearest lot line----------- 4_____________________ t, <br /> 9 / repairing ) ------------------------------------------------ ----------- <br /> Remodeling <br /> -------- - <br /> t <br /> Remodelin and/or re airin describe :------_-----_________ __ ________________ i <br /> ----..------------------------------ -- <br /> ---- <br /> -------••-------------••---------- A { <br /> --------------------------------------------------•--------------------------------------------------------------- <br /> -------------------------------------- <br /> ----------------------------------------------------------------------------•-------- ------------------------••-----•-----------------------------------------------------'------- <br /> t f' <br /> I hereb cerci that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, $ to ws, and r les and regulations of the San Joaquin Local Health District.f' <br /> t <br /> (Signed)------ - - - -- -------- -- ---- ------- -------- -------- _ )1 <br /> -- -- --------- _ <br /> �By:------------------------­-- -- -------- -- ---- {Ti -le or <br /> ner and/or Contract <br /> - <br /> (Plot plan, showing size of lot, location of system in relati o wells, buildings, etc., can be placed on reverse side).' <br /> FOR DEPARTMENT USE ONLY t <br /> APPLICATION ACCEPTED BY -LL. r -_ ----�� ---------------- <br /> ----------------------------------------------- <br /> ------ DATE------19_ <br /> REVIEWED BY-------- ------------------- ------ DATE------- <br /> BUILDING PERMIT ISSUED----------•------------------------------ ' - ------ ------ DATE------------------ <br /> Alterations and/or recommendations: € ------------------------------------•-------------------------------------------•---------------••--------------- <br /> --------------------- <br /> A. . <br /> ------------------------------------------- , <br /> t <br /> FINAL lNS - Date------.. <br /> S SAN JOAQUIN'tOCAL HEALTH DISTRICT <br /> 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 105 West 9th Street <br /> Stocklon,California Lodi,California Manteca,California Tracy,California <br /> CS 9 REVISED 6-59 3M 31'63 F.P.C . - <br />