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FOR OFFICE USE: <br /> -------- ---- ---------- --- --- ---- ------------ <br />----------------------------- -------------------- -- ---- APPLICATION FOR SANITATION PERMIT Permit No. ,2_.r�_.a_f <br />---------------------------•-- ------------------------- (Complete in Duplicate) <br />---------- --------- ---- ---------- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is he,r'eby made to the Sari Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This applicaf.ioti-is,riade,in_cp�mpliance with-County Ordinance No. 549. <br /> � 6r(o 7—,,J K.,6 1/J.-/,S,DJfl) <br /> 14-' <br /> fI <br /> JOB ADDRESS A LOCATION ----------------- <br /> - --`'----- <br /> Owner's <br /> ----- <br /> Owner s Narne_ �L�-----w1c. --------- --- ------- ------------------------------------ Phone------------------------------------ <br /> r -------------------------- <br /> ----------- <br /> Addre s............. .. ------ <br /> nf�actor's Name------- -------------- Phone. <br /> ---------I--------- <br /> .0- -. r <br /> -------- ---- -- - --- ---4---------------- --- <br /> Installation will serve: Residence [?r�Aparfment House [_1 Commercial [] Trailer -C"ourt' Motel Other 11 <br /> Number of living units. I--- Number of bedrooms .3---- Number f'b--aths --- Lot size ---- �:..`��'---------I--------- <br /> Water Supply: Public system E] Community system ❑ Private Number <br /> Depth f• ater Table -------- ft. t p4 <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam Clay Loam E] Clay E] Adobe [:] Hardpan E] IS- <br /> Previous Application Made: I I f yes,date--------------------) No E] New Construction: Yes E] 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.) 'N <br /> Septic Tank: Distance from nearest well----------------Distance from foundation--------------------Materidi------------I------- ----------------------------- <br /> E1 No. of compartments--------------------------Size--------------------------------Liquid depth---------------- ---------Capacity----------------------- <br /> Dispose-field: Distance from nearest well_._-XP.-`..Distance from foundat'on------�P.........Distance to nearest lot line--c------------ <br /> Number of lines...-_--__--_-/---- -- Length of each line--------44----------------Width of trench____:_-------------------------- <br /> Type of filter material---------OU-_-Depth of filter material____ _---_____Total length--------i(,&---------------------------- <br /> Distance to nearest well--------/-OP------Distance from foundation------Z_0---t--.Disfance to nearest lot line--._r-------- <br /> ❑ - <br /> Number of p:fs--- ----------Lining material__!r_S-1.0.Z_j------- --/0- Dept h........../0--"------------- <br /> Cesspool: Distance from nearest weii-----------------Distance from foundation... ............... Lining material_...___._________.__________.____.__ <br /> Size. Diameter. -------------- ----------------Depth---------------------- ---------------------F -------Liquid Capacity.. -----------------gals. <br /> Privy: Distance from nearest well---------- ---------- ---------------------- --.-Distance from 'nearest ,building-------------------- ---------- ----- <br /> El Distance to nearest lot line------ ------------------- ------- ----------- --------------- ----------- -------------`�---- ------------------- ------- <br /> Remodeling and/or repairing (describ ) -------- ----------------------------------------------------------------------------- <br /> ------------ ------------------------------- <br /> -----------------------------------------------------------------t--------------------- --------------------------------------------- -------------------------------------------------------------------------- <br /> --------------------------------------------------------------- ----------------- ----------------------------------------------- <br /> ------------------------------------------------------------------------- <br /> ----------------------------------------------------------------- -•---=--•----------------- <br /> I hereby <br /> 1at I have'prepared this application and that the work will be done in accordance with San Joaquin County <br /> -P <br /> ordinanceand rules and.',regulations of the San Joaquin Local Health District. <br /> (Signed)----- ------ -- - . ..... ----- -- --------------------------- -------------- -------------------------------..—_—_---4GWaw_pnd/or Contractor) <br /> By:--- --- ------------- -------- -------------- ------------------------------------------------------(Title)---------------------------------------- ------------- ----- --- <br /> 4y��in re(II I' I <br /> (Plot plan, showing size of lot, location'of ysfem in tion to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__4:A1 141111-21-Z------ -------------------------------------------------------------- DATE__ ------------------------------- <br /> REVIEWEDBY------------------------- ---------------------------------------------------------------------------------------------------- DATE- <br /> BUILDING PERMIT ISSUED-------------------------------­---------------------------—-------------------------------------- DATE___ <br /> Alterationsand/or recommendations:---------------- --------------------------------------------------------------------------------------------------------------------------------•------------- <br /> t <br /> -----------------------I------------- <br /> ---------------------------------------------------------------------------- - -------------­_­------------------------------------------- ----------------------­---------------t-------------------------I—---------- <br /> I <br /> ---------- ---- ------- --------------------------------------------------- <br /> ---------------------------------------------------------------------- --------------------------------------------- ---------------------------- <br /> --------------------- --------------------------- -- ------ -------- - -- ----- ---------------------------------------------------- -------------- ------------------------------------------------------------- <br /> ------------------------------- - - -- - --------- ------------------------------------------------------------------------------------------------------------------ ---------- ----------------------------------------- <br /> FINAL INSPECTION' --------------------- /-S-77-d-1.1...... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7601 E.Harelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy, California <br /> F.P.CU. <br />