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/FOR OFFICE USE: / r <br /> -� ---------------------/a--'3 Permit No. <br /> APPLICATION FOR (SANITATION PERMIT _ <br /> ------------------------------------------------ _ <br /> ------------------------ --------------------------- <br /> (Complete in Duplicate) Date Issued-_____� .""_G/ <br /> ---------------- ------------- --- --- <br /> -__.-_- This Permit Expires 1 Year From 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 /> t9 <br /> JOB ADDRESS TD <br /> LOCA�TIO�N___1---_ ----�-- --------------------------- ------ <br /> - ---- <br /> Phone-------- ---------- <br /> elf, r------------------------------------------------ <br /> ' Tf - - - -. <br /> Owners Name- -g--... -- <br /> Address-------- v -----��. --------- ---------- --• --------------------------------•--------•------------------.._..--------------------•---------..__.....------.. <br /> Phone---------------------- <br /> Contractor's . -----••---••-•-------- <br /> Installation will serve: Residence Apartment House ❑ Commercial [3 Trailer Court ❑ Motel [3 Other [j <br /> l Number of.living units:_ --_ Number of bedroom <br /> .Number of baths. Lot size.----7j_x---47� --------------------- <br /> Water Supply: Public system'❑ Community system'[:] Private [B— depth to Water Table ft. + <br /> is <br /> Character of soil to a depth of 3 feet: . Sand Gravel El <br /> Loam El Clay Loam E] Clay ❑ Adobe❑ Hardpan C3 <br /> Previous Application Made: (If yes,,date--------------------) -No New Construction: Yes K3--No E] FHA/VA: Yes ❑ No [�- <br /> i <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ' - <br /> I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> I <br /> Septic ank: ' Distance from nearest well_______________Distance from foundation--------------------.Materia---------- --------------------------__ ____. <br /> �No. of compartments----- ---------Size-------•-------------.------ ---Liquid depth---;-----,! --------------Capacity--------------` <br /> _____._._Distance from foundafion_.A�.-.___--""-Distance to nearest lot line__0---------- <br /> Disposal field: Distance from nearest well--- <br /> Number of lines------ --------------------------Length of each line-----_7,5........---- --Width of trench----��-_5---------------""-"-- <br /> Type of.filter material-- I -___--___=Depth of filter material__t�_ _________:Total length------ ,��_________________________ <br /> Seepage Pit: Distance to nearest well_____.':'r'7' Distance from foundation__________________.Distance to nearest lot line_____-._______--_ <br /> Number of pits----------------- ---*Lining material----------- ----------.Size:-.Diameter"" Depth S <br /> Cesspool: Distance from nearest well__ ____"'"'Distance from-,foun�dat n__.---------`-----.Lining material__-____�___________________________ <br /> Li uid Capacity --------------------------gals. <br /> ❑ Size: Diameter# ------ ----------- Depth-------- ----•---- ---------------------- 9 p Y <br /> Distance from.nearest.building <br /> Privy: Distance froin nearest well---------------------------------------- -------------------------- <br /> ❑ Distance to nearest lot li -------------------- <br /> + � { F ti <br /> a- <br /> Remodeling and/or repairing'(describe)----- ---- ---------------------------------------------------------------------- <br /> foe <br /> --- ----- -•--------------------- <br /> rf. ------------------ ------------------------------- <br /> ------------- <br /> -------•------------- -- <br /> I <br /> I, :. <br /> ---•-------•-----------••-------•------- <br /> ----------•------------------------- <br /> --•--------------------------------------------------------=-------- ---------•-------------------:------ <br /> 13F I <br /> i hereby certify that l r pt ared this app ati nand at the work will be done in accordance with San Joaquin County <br /> ordinances, State. laws, and rules and regulations of- t San aquin Local Health District. <br /> caner and/or Contractor) <br /> (Signed)' By:---- --------------------------,. Tttle <br /> _ __ <br /> g ; - ----- --------------- ( ---------------------- ------------- ------------- <br /> ----------------- - ----- -- ---- - -- <br /> (Plot plan, showing size of lot, loca ion of s em in r 1 on to wells, buildings,,etc.,.can be placed on reverse side). <br /> FOR-DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE-.-------• :7 (� <br /> REVIEWED. BY--------------------------------- -- ----)-- -------------------------- DATE <br /> BUILDING PERMIT ISSUED------------_ ------------------------------------------------ DATE ` <br /> Alterations and/or recommendations------------------------------------------------- ----•-----•----------"""--- -"""-----"""" -----" <br /> ---------------------------------••------------------------- <br /> ------------------------------------------------------------ <br /> -------------------------------------------------- <br /> --------------------------------- <br /> ----------•---------------------------------------- <br /> / . <br /> FINAL INSPECTION BY: [�l/ ------- ----- Date <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s 124 5 camore Street 205 West 9th Street <br /> 1401 E.Mat:elton Ave. S 300 West Oak Street Y <br /> Stockton,California t Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED B-59 3M 3-'63 F.P-CC. <br />