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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT permit No. .t .....r� <br /> -------------------------- -- - ----------- - <br /> .........:....... ... ... .. _ (Complete-in Duplicate) g� <br /> 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 L CATION---� <br /> 541 <br /> JOB u` '--------- <br /> ------- '------- <br /> a <br /> Owner's Name----- --• --- - -- -- - - -•------ -� . _ ..:..--------. .. Phone_ <br /> oee <br /> AddressdT ` ---- --- ------� -- ---------`-------- --------4-------------------------•--------- ... <br /> Contractor's Name_. ~ - -"Z�_ f'�------ ----- - --------------------------------------------- Phone..---- .�..: w- <br /> Installation will serve: Residence ❑ Apar ment House ❑]Commercial ❑ Trailer Court ❑ Motel [:1 Other E]__7_Number of living units: _ Number of.bedrooms _D--- Number of baths__ _ Lot size _____ ___ ______•- -----.-. - <br /> Water Supply:.-Public system {] Community system ❑ Private �( Depth to Water Table ------ _ ft <br /> Character of soil to a depth of 3 feet• Sand ❑ Gravel ❑ Sandy Loam M Clay'Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date--.-------------- 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.) <br /> Septic Tank: Distance from nearest well_f El0__f._Distance from fo ndation__._.l�_-� --_.- It� <br /> - -----.Material '. <br /> No. of corn artments_ +3. Size_ �� <br /> ,- �' � P ✓--- .�. �- -��-1( -_,•fie_Liquid depth_'.:- Capacity_Jaa6-_ <br /> Disposal Field: Distance from nearest well- 1 Distance from foundation._.AV..____.._.Distance to nearest lot line_•'_____._____ <br /> Number of lines-------- Length of each line-_ ...........Width of trench_._4--_--------------------------- <br /> Type of filter material-_._ _� ------Depth of filter material------/_ ' _-_...Total length----tea-0------------------------- <br /> S4;�* Distance to nearest ell------- -------------Distance from foundation____®:__:...__.Distance to nearest lot line_.-_ ------- <br /> ❑ Number of pits__ . . --- -------Lining material__..SJZ -__ Size: Depth---/.X----_____________________ <br /> Cesspool: Distance from nearest well ----------------Distance from foundation.-....----------- ..Lining material-------------------------------------- <br /> El Size. Diameter- -- --------- --- - --- ----------Depth-------------------- ------Liquid Capacity- ---------- ---' gals. <br /> Privy: Distance from nearest we]--------------------------------------.-........-Distance from nearest building-------------.-------- ----------------- <br /> pDistance to nearest lot line -------- --- ------------- ----- ------------•------------------------------------------------------------------- ------ ----------- <br /> Remodelingand/or repairing (describe) ----------------------------- -------------------------------------------------------------------------- -•--------•---------------------- --------- <br /> ------------------ -------------------- ------------ ----- --- <br /> ------------------------ ----------- ------------------------------------------------------------------------------ --------------------------------------------------------------------- -------------:----------------- <br /> I hereby cer' that I have prepared this application and that the work will be done in accordance with San Joaquin-County <br /> ordinances, Stat ]a s, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)----------- --------- ------- --.... ... .......... ---------------- ----- nd/or Contractor) <br /> By:------- --------- --- f---- ----- ------- -- ------------------------------(Title)----------------- -------- ----------- ...... . ----------- <br /> (Plot plan, showing size of lot, location of syst m in relatio to wells, buildings, etc., can be placed an reverse side]. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-.,-.--" . _ _ _ --------------------------------------------------- DATE_J?=,_)-4_ .---___-- <br /> AREVIEWEDBY--- -------------------- ---- --- - - ----- ---------------------------------- DATE------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED-------- -- ------------------ - - ------- ------------------------------------ ------ DATE---------'--------------------------------- ------------ <br /> Alterationsand/or recommendations------------------ -------- --------------------•--- ---------------------------- ----------------------- ---------------------------------------------------- <br /> ---------------- -------------- --- ----------• ------- ----------- ---- - ------.---------------------------------------::------------.._._. -------- --------------------- ------------------------------------------- <br /> FINAL INSPECTION BY:., - Date--`. d" .............. t <br /> • F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore street 205 West 9th Street <br /> Stockton,California Lodi. California Manteca,California Tracy,California <br /> E.H.9 2M 1-67 Vanguard Press <br />