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1� Permit No. <br /> APPLICATION FOR SANITATION PERMIT ��-a__3.3__-___ <br /> IV (Complete in Duplicate) 7 4 /S <br /> Date Issued --_-= __----___-_-- <br /> Application is hereby made to the San Joaquin Local Health District for a permit construct and install the-work herein described. <br /> This application is made in co i�pliance with ounty Ordinance No. 54 <br /> ' <br /> JOB ADDRESS AND OC AT N---- - -- - - - --- --------- f - ----'-l� l��---------------------- --- ------- <br /> rPhone-------------------------------- <br /> Owner's Name-------- - ----- -- - - ---------------------------------- <br /> / APAddress- � .•-- F •s•----------- �" <br /> Contractor's Name------------------ = --------------- Phone------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court []"'Motel ❑ Other ❑ <br /> �. f <br /> g / ---1k1-1.1% ---------------------- <br /> Number ______-- Number of baths __ - Lot size -__ <br /> Number of living units:.) <br /> Water Supply: Public system-'IE] Community system Private ❑ Depth to Water Table .1�0_?ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel Sand Loam Clay Loam Clay Adobe Hardpan <br /> p �� ❑ ❑ Y ❑ Y ❑ Y C� ❑ <br /> Previous Application Made: Yes E] No � New Construction: Yes R5-- 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 /> ------ <br /> Septic Tank: Distance foga;nearest well----=G�-----Distances tom foundation �� Material <br /> I'� No. ofcompartments_-___ ,._______________Size__ __ __ __ _Liquid depth_.- _ --- -_:Capacity- Qr -___ <br /> Disposal Field: Distance from nearest well___"- n------_Distance from foundation__AA_---------Distance to nearest t line---%.5--------- <br /> f en }h of each line--____ +' ` - Width of trench____ _________________ <br /> � Number of line-------- --------- --- g <br /> Type of filler material_ _--_Depth of Filter mater al_-_Z -_- Total length-�__- - __--_-_____---_----- <br /> Seepage Pit: Distance of to nts resig, ell------„Linin-- -Die rake_-Y' o �Size:nDia �r•__•.D t p;e to nearest to lire <br /> _._ - <br /> Numbe <br /> meter__. ___.-.--.De tn.-.- <br /> - • - � x <br /> Ap ---- g - <br /> Cesspool: Distance from nearest well----------------- from foundation-------------- -----Lining material__-----------------__-_____.___------ <br /> ❑ ize: iam e'er-------------------------- ----------De6th----------------------------- ----------------------Liquid Capacity-.---------------------------gals. <br /> Privy: Distance from nearest well--------------------- -----------------------Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot <br /> i <br /> � <br /> line-------------------- -' <br /> ------------------------------ - ----------------------- <br /> Remodeling and pairing' (describe): ---- <br /> /or re <br /> I------- ---------------------------------------- --- <br /> ------------------------ ----------------------------------------- <br /> ------------- --- <br /> Il .� -- <br /> ---------------------------=----------------------------------------------------------------------- -•-----------•----------------------------------­-j-------------------------------------------------------------------- <br /> 'I!' I <br /> ------ -----------------------------------------•-----------•--------------------------- <br /> 'II' 3 <br /> ------- ----•------------------------------------------------------- -------------------------------------------------------------------- ------------ <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 laws, and rules les and regulations of the San Joaquin Local Health District. <br /> 1 <br /> a <br /> Si ned Contractor) <br /> - ------------- <br /> By=----------------- --------'---•- 6�r` f (Title)- ------------------------------ <br /> of <br /> �----------------------- <br /> ----- <br /> (Plot plan, showing size of lot;)locati f system in relation to wells, buildings, etc., can be placed on reverse side). <br /> 1n <br /> tKI _-_FOR_DEPARTMENT USE ONLY t <br /> APPLICATION ACCEPTED BY---- ._ - � DATE �'_---- --� <br /> �` <br /> REVIEWEDBY-------------------------�--------- ----------------------------------------- ---------------------------------------------- DATE------ -------------•--------------------------------------- <br /> BUILDINGPERMIT ISSUED---�--------------------------------------------------------------- --------------------------=------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations-------------------------------------- -- -------------------------------------------------------------------------------------------------------------------- <br /> II _ __ __ <br /> --------------- '---------.--------- �'-------• ---------- ---------------------- -------------••------------- --- ---------------- ------------------------------------ -- ----------------------- <br /> \A& -) " � ` � <br /> E FINAL INSPECTION BY:..- V�-� Date---- ------------ -- <br />�. SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> 130 South American.Street 300 West Oak Street i32 Sycamore'Sfreet\ 814 North "C" Street <br /> I Stockton, California iI Lodi, California i Manteca, Califoreial ' Tracy, California <br /> i <br /> ES-9—•2M . Revisea 1-57 F.P.CO. V <br />