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1Go� a VntV�­ <br />q -z- ( APPLICATION FOR SANITATION PERMIT <br />(Complete in Duplicate) <br />Permit No. __l__(//_ 7,3 <br />Date Issued _____ 4.....!. <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 o. 549. <br />JOB ADDRESS AND LOCATION ' -- • -- . ---- <br />Owner's Nam X. til ---- -- -----.Z-- ---- ---------------�------------------------ Phone ------------------------------------ <br />Address - ��-------------f�' <br />Contractor's Name---------------------------------------------------------------------------------- Phone <br />Installation will serve: Reside Apartment House ❑ Commercial ❑ Trai`er Court ❑ Motel ❑ Other ❑ <br />Number of living units: •----_ Number of bedrooms ---/-_ Number of baths ___Y. Lot size ------- __________________________ <br />Water Supply: Public system ❑ Community system A Private ❑ Depth to Water Table ISft. <br />Character of soil to a depth of 3 feet: Sand ❑ Gravel Sandy Loam ❑ Clay Loam K Clay ❑ Adobe ❑ Hardpan ❑ <br />Previous Application Made: Yes ❑ No New Construction: YesWNlIr9 E]FHA/VA: Yes E:1 No <br />G <br />TYPE OF INSTALLATION AND SPECIFICATIONS: wlvr� <br />,(No septic tank or` cesspool permitted if public sewer is available within 200 feet.) <br />SOispqsal <br />ptic Tank- Distance from nearest well ----------------- Distance from foundation -------------------- Material ------------------------ -.--__._____._-.__--_- <br />No. of compartments --------•----------------- Size -------------------------------- Liquid depth -------------------------- Capacity ----------------------- <br />Fi I Distance from nearest well ----------------- Distance from foundation .................... Distance to nearest lot line -_______--__---•- <br />Number of lines ----------------------------------- Length of each line ------------------------------ Width of french ----------------------------------- <br />Type of filter material ------------------------- Depth of filter material -__-_-_-_-______-_---_Total length ------------------------------------ <br />Seepage Pit: Distance to nearest ell --- ,�40-0-_''Distance from foun ation...... �,�-__..Distance to nearest to line__._ <br />Number of pits------------------�iwiNe�eterial5A1 ?_,i_eter_-.---------.---------- Depth__._ . ''(- -r------.----- <br />Cesspdol: Distance from nearest well Distance from foundation Lining material ------------------------------------- <br />....❑1771 <br />Size: Diameter -------------------------------------- Depth ----•----------------------------------------------- Liquid Capacity..-. ------------------------- gals. <br />Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building ______________---__-___________..__.___... <br />❑ Distance to nearest lot lineyl;----------------------------------------------------- <br />Remodeling and/or repairing (describe :-- --- ` - ----- r.....4�-- -------- ----------••----_--•-- <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 I ws, and rules and reg s of the San Joaquin Local Health District. <br />(Signed)'' - (Owner and/or Contractor) <br />By: --------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- <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 />APPLICATION ACCEPTED BY--------- ----------------------------- - --- ---- -----------------------•-----------_--- DATE ------- ------------ <br />REVIEWEDBY -------------------------------------------------------------- -- -- -- - - •------------------- DATE------- %r-�--� D_ ''-0------------------------ <br />BUILDING PERMIT ISSUED --------------------------------------- ------------------------- DATE-------_----------- ----------------- ----------------- <br />Alterationsand/or recommendations:_-------------------------------------------------------------------------------------------------------------------------- ••--------------------------- <br />-----------------------------------------------------------•------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- <br />----------- ------------------------------------------------------------------------------------•------------------------------------------------------•----------------------------------------------------------------------- <br />---------------------------------•-------------------------- --------------------------------------------------------------------------------------------------------- ------------------------------------ <br />----- <br />-------------------------------------------------------•--------------------- ------ --------------------........................ <br />FINAL INSPECTION BY------------- /A-- ---- Date- --------- 4___0___6- �-------------------- <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br />Stockton, California Lodi, California Manteca, California Tracy, California <br />ES -9-2M , Revised 1.57 F.P.CO. <br />0 <br />SIX <br />.01 <br />