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'FOR OFFICE USE: <br /> ---------------- A, 7 <br /> _[- -------------------- APPLICATION FOR SANITATION PERMIT <br /> if ­1 Permit No. <br /> ------------------ (C <br /> --------- -------------- (Complete in Duplicate) <br /> 'Thit 66te Issued ------5. ......... <br /> - <br /> ----------- ---------------- I------------- ­ -4ermit Expires 1 Year From Date Issued t <br /> Application is hereby made to the an Joaqlin Local Health District for 6 permit to construct a d install fhe work herein described. <br /> This application is made in compliince with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATIONefa' <br /> j <br /> Owner's Name------Wf�.. Ph' <br /> -----------7­--------------------- --- ----- ---------------------------------- on <br /> 12L_ <br /> Address._ <br /> --------------------------------.................... <br /> .............. <br /> Contracto'r's Name ----------------------------------------------------- ----------- Phone.-------------- ---­-------------- <br /> lnstallation`will serve:; Residences A E] <br /> Apartment House ❑ Commercial El Trailer Court Motel 0 Other <br /> Number.of living 'Units: --------- Nu miber of bedrooms- Number of baths .1.____ Lot size -----­-­-------- <br /> Water"Supply: P.u blic's'yst'ern 0 Community system El. Private PQ Depth to WatWfable ff. <br /> "'It4_4 Char3cfor-�of,s(i-'fb-ardepfh of-3 feet: tSand-E] Gravel ESandy Loom EClay Loam 0 Clay ❑Adobe Hardpan E <br /> No ❑ PHA/VA: YC No <br /> Previous Application Made: (If yes,date----O <br /> - No New Construction: Yes <br /> Yes <br /> TYPE OF INSTALLATION ANDSPEC IFICs:,V0Z- 0 �j <br /> (Noseptic tank'or-ce-sspo;I,,p6-rmiffed if.,.pu@ic sewer.,is ayailable,within 200 feet.) <br /> " I , . ;- <br /> Septic Tank: Distance from n <br /> earesf well- R -Distance from foundation____W---------M6ferial-ReD-WIT)-------- <br /> No�-of compartmenfs!*,__,'2_ Liquid depth____-tel Capacit�---vbnidi�� <br /> ir--------------- <br /> -4, y <br /> Disp Cseld:" '-Distan'�e�from nearest.well`+ --t-Distance from foundation---U-0-----------Distance to,nearest lot line_________________ <br /> ? . 1P <br /> f-;f*rench-----2-,;%---------------------- <br /> ,au er -----------�_-_�_ __Length of each line_.._.__g.0.1-----------Width o <br /> T <br /> ype-of filt rim :terial--- <br /> material----- ------Total .length---------14-0-------------- <br /> P�OT"ZIT !6epth oftei <br /> _�_ - - x <br /> Seepage Pit: Distance to nearest.well--- �4j -�616arest lot.line_________________ <br /> '0_67- .!,7(t"an"77 u-ri�ation--- Distance <br /> Number of-pits------�st <br /> -------------LinigmafdriaL.-ro C Size: Diameter---- �Npfh___SJCessp�ol: Di tance from,neawell-------- ---,,--.Distance from foundation--------------------Lining material------------1_____.--------•----._.. <br /> 1_5----------- <br /> ffSize: Diameter!-------------------- ------Depth ------------------------------------------Liquid Capacity---- .-------------------gals. <br /> Privy: Distance from 'nearest well ------- ------------------------- <br /> --------- ....Dis�ance from nearelf building________________---------------------- <br /> + r�, .! - ------- -V . - - 1 <br /> El ------ ---------------------------------------------- --------- -------------------------------- --------------------- <br /> Remodeling and/or repairin.g (deicr I ibe):----------=-----=-=----------- ---------------------------------------------------4 ---------------------- <br /> ---------------------­------­ --------------------------------------------------------------- . .. ... -------------------------------- ----------------------- <br /> ----------------------------- <br /> ------------------------------------------------------------------------------------------------7------------- -------..........I--­-----­---------------------­------------------------------------------------- <br /> ----------------------------------------------------------- ---------------------------------------------------------------------------------------------------------I---------------------------------f------------------------ <br /> I hereby-certify that-I have prepared this'application and that the work will be done in accordancewithSan Joaquin County <br /> ordinances, State laws; and rules and regulations .of the San Joaquin Local Health District. <br /> (Sign n <br /> ed)--- --- ------------------- ------------- --------- ------------------------------ ----(Owner and/or Contractor) <br /> -------------------------------------------- <br /> By:----------------- <br /> -� '. i <br /> -----------------------------------------------------------------------------------------------------------------------(Title)----- ---------------------------------i......... ------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> T <br /> APPLICATION ACCEPTED BY-----% —------------------------------------ D ------ <br /> REVIEWEDBY_----------{------------------------------------ ------------------------------------------------- -­----­------------- DATE-)-------------------------------- ----------------- ... <br /> BUILDING-PERMIT ISSUED----------------------------------------------------- ----------•------------------------------------ DATE--- ------------------I------------------------------------- <br /> Alterations and/or recommenatioqs ------------------------------;---------- ... .. ....... ------------------- <br /> ----- --- ------ ­----------------------- <br /> --------------------------------------- ---------------------------------------------------------------------------------------:------------------------------------------------ ------ ----------------------- <br /> I <br /> ------------------------- ----- ----- ------------------------------------------------------------------------------------------------------------- .........�j <br /> ------------------------------------------ <br /> ­--------------------------------------- -------- ----------------------- <br /> --------------------------------------------------------- ............. ----------------------------------------- <br /> FINAL INSPECTION BY:'.%,7-— - ------------------------------------------------ Date---9--j-3--`7-•- _ ------------------------------------------- <br /> t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br />