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FOR OFFICE USE: * ' <br />-------------- -- -=----------------------------------,_ <br /> h.. <br />-------------------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. -r�___tJ����_ <br />------------------------- ----------:------------------ (Complete in Duplicate) 3 a <br /> Date Issued <br />--------------------------------------------------------.._ This Permit Expires 1 Year From Date Issued r. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descried. <br /> This application is made in compliance* County Ordinance No. 549. <br /> � <br /> ---- ArT—W—F4------------------- <br /> JOB ADDRESS AN�LOCATION.. � = --- Phone----------------------------Owner's Name r T 1 ----- k <br /> Address--------------------- - -•- <br /> - ---------•-• -------------- ------------------------- <br /> ----__ <br /> 3f��Z <br /> - �- -------------------Contractors Name hone <br /> Installation will serve: Residence ❑ ; Apartment House ❑ Commercial railer ,ourt ❑ Motel ❑ Other ❑ <br /> Number of living units: _.____ Number of bedrooms ________ Number..of�baths(} _ __ ze ____ <br /> -------- -------- <br /> Water Supply: Public system Community system [IPrivate j;-�Dpth to Water Tablet�_ f#. <br /> Character of sI o a depth of,3 feet: Sand ❑ Gravel ❑ Sandy Loam[+Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> r, <br /> Previous Application Made: (If yes,date--------------------) No 94--`!�ew Construction: Yes Kj- o ❑ PHA/VA: Yes ❑ No [�r� <br />--.i-TYPESOF-INSTALL'ATION.rAND1.SPECIFICATIONS-- <br /> (No <br /> PECIFICATIONS-j(No septic tank or cesspool permitted,if.,publicssewer.is availeble,within,200,feet.) , <br /> _"'Distancef f � r � hfrom founndation__f D�x___NMateriai__ _�-- �--- <br /> Septic Tank. from nearest well__.__-_____._.__Distance - � -------------- ---------- --------•-- <br /> NNo. of compartments`"""'"`" -....__5ize_�z��� __Liquid depth ..t Capacity_fSt .. _ <br /> X A <br /> Disposal Field: Distance from�ne&est w�ell�t_� Distance from foundatioy'n_ istance to nearest lot lin�,5____ <br /> Number of line --- �""-� `" "'"Lerigth of each�e__=�L1� �'_ Width of trench �_�_____ ` -_____._ --_ 4 <br /> Type of filter material-__ ,[ Depth of.filter material_. A�� T.t l length__.=" :________ . ___-__``_��__��_ , <br /> Seepage it: Distance to nearesf'� ell .�dr0_. // <br /> ' "_`Distan e m fon ation" _-{�--�?Distance to nearest lot line <br /> i '4 ..Si,,: Qiameter !C p <br /> Dumber of pits------- ------------- material-� - - � --- --- ---- De th �-------•-----<-------- rJ . <br /> Cesspool: t �D;istance.fiam"nearest we I'�- __'Disstance frokm�foun.dation :"_.Lining material--_ ------------------------------- <br /> OA <br /> ______________ _ ______- <br /> ❑ "'"Size Diameter_:. - - --------� .> =_Depth------ --!Liquid Capacity---- -------------------gals. �. <br /> Privy: !` Distance from nearest well____________________ �-_______..=.___t` Distance from nearest building----------------------------------------- <br /> ❑ Distance --- <br /> to neares}lot line------------------- `*5-------------------- ----------------------- -------------------------------------------------------- ---- <br /> - <br /> Remodeling and/or repairing (describe):------"- -Q_TE..---- - --- <br /> ------4#10v7C---�h� D1#►,E. 1[A� 13 `PXt Fiq ` v�11 .tom D�SPO� -----------------'° -- <br /> R Qmm_�NR .' Nf tI-Rf�f_C� __ <br /> ------- ------------ - -- ----- -------------- ---- <br /> t I hereby certify th;t l have prepared�fhis applicatio nd that the work will be done in accordance with San Joaquin County <br /> ordinances, Sta laws, an ,rules and r gulat• nslof the San�:Joa uin Local Health District. <br /> } _ , <br /> Si ned ----- ------- -- - ------&_ �bwner <br /> -- --- and/or Contractor)------------- <br /> Plat plan, showing size of lot, location of system in rel n to well u Title e <br /> By ------------------ ---------- '�;. { ) <br /> ------- <br /> (Plot s buildings, etc., can be placed on reverse side). <br /> `# FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------T,_-#_R:t0---• ---------',2------ ----- ------ ----------------- ------------- DATE--- ----------------------- <br /> t --- DATE------------------------------------------------------------ <br /> ----------------------------------- <br /> BUILDING <br /> BY------------------------ -------------- ---- <br /> BUILDING PERMIT ISSUED--;-------­­ <br /> - ••----=---------------------------- DATE---------------------------- ----------------------------- <br /> Alterationsand/or recomme�tions:------------- -------------------------- ----------------------------------------------- ------------------------------------------------ <br /> - _r---------------------------------------•----------------- --•------------------------------••--------- <br /> ------------------------------------------------------------------1 ------- ------------------- ---------------------•------------------------•----- <br /> PENAL INSPEC Date-------- ----- -/-5 `------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> " 1501 E,Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street 'I <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F.P.CO. <br /> 1 <br />