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FOR OFFICE USE: j <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------------ -- ----------- <br /> ------------ ----------------- <br /> ---------------- ------------------------- ---------- (Complete in Duplicate) Date Issued ____T6�,}S 6 S <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 h reip i deed. <br /> This application is made in compliance i h o,un y Ordinance No. <br /> JOB ADDRESS AN LOCATION_1_ Ye!_._, I�aiK------ --`h <br /> --- <br /> - <br /> o ------ <br /> Owner's Name------ ----- rte" --------------------------------- ------------------ Phone <br /> Address------------------- ..�2 -�= 5 � ---7----- ------------------------------------------------------------------------------------------------------ <br /> Contractor's Name------ 4 r --------------------- - Phone----------------------------------- <br /> Installation will serve: Residence [Ej� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: r(------ Number of bedroom_-_-- Number of baths/------- Lot size ---- :__—------------------- <br /> Water Supply: Public system ❑ Community system ❑ Private 9/ Depth to Water Table -------- ft. <br /> l <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe❑ Hardpan ❑ <br /> Previous Application Made: (Ifyes;date-----------.---_----} No ❑ New Construction: Yes ❑ No E] 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 /> } <br /> Se ticxTank Distance-from nearest well---------------_-Distance from foundation-------------------Material------------------------------------------------ <br /> 'El <br /> _-_-_----_.--_-------.'❑ No. of compartments--- ----------- ---Size-------------------------------Liquid depth------------ -------------Capacity-------------- -------- <br /> Dis os Field: Distance,from, arest well-�P..--f_Distance from foundation-------/4.------Distance to nearest lot line_S_---_--__- <br /> P Number of lines_________ ___ _ __ Length of each line----I-D-6---_o____.__:Width of trench____ -- ------------------------ <br /> ---- <br /> ---_-----------______- h 1 <br /> — yy�� <br /> sem. Type 'ofTfilter material___/Z--__----_-.Depth of filter material-----J... -----.-Total length----f-.c-C'------------------------ <br /> Seepag i Distance to nearest well __--__-1Distance from foundation-___1A1----- Distance to nearest lot lin�e_3�_�------ <br /> Number of pits_-�----,I<.___._______Lining material--- Diameter------- 3..__.__..Depth-- S-_____________________ <br /> Ce"sspool: Distance from nearest well______-----------Distance from foundation-.- --.____.Lining material-------------------------------- <br /> ------ <br /> Al Size: Diameter--- - ---------------------- - ------Depth--------------------- ---- ---------------- - Liquid Capacity-------------------- -----ga s. 10 <br /> P`rivy: Distance from narest well ------------------------------- ----------------Distance from nearest building.____..___.------ ------- e <br /> e � <br /> i <br /> 1r ❑ Distance to nearest lot line- --- -------------------------- - --------------------------I-------------------------------------------------------------------- <br /> r Remodeling and/or repairing {describe :-_---- ' <br /> --------------•-•- •-------------------------------------------------------------------------------------------------- t <br /> f` --------------- <br /> l . <br /> ,Y <br /> ____________------------------------------------------------I------------------------------------ --------------------------------------­------------------------------------------------------------------------------ <br /> I <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 laws, and rules and regulations of the San Joaquin Local Health District.' <br /> (Signed) --------------------------------------- af,1d/or Contractor) <br /> --- Title <br /> By= D (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------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED-------------- -------------------------- ----------•---------------------------------------------- DATE------------------------------------------------------------- <br /> I <br /> Alterations and/or recommendations--------------------- <br /> 4 <br /> ------------•--------------•---------- ---------------------- ------•-•------ -----------•------------• -------------•-------------------------------------------------- ----------------------------------------------- <br /> -- ----------- -- -------------------- _ <br /> _ —FINAL INSPECTION <br /> BY .- -- <br /> - _r r <br /> - ._ Date- r <br /> za b1 <br /> SAN JOAQU.IN•LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Are. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> r { Lodi California Manteca,California Trac California <br /> Stockton,California 3 + y��� <br /> rs 9 REVi5EO 8.59 3M 3-'63'F.P.CC- <br />