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FOROFFICE USE- <br /> ------------Afl-f:,2!;---.. <br /> SE-------------Af/'-f:,-----.. <br /> --------..--------------------------------------------- APPLICATION FOR" SANITATION PERMIT Permit No. + . <br /> --------------- ------------------------------ (Complete in Duplicate) <br /> --------------------------------------------------------- This.Permit Expires 1 Year From Date Issued <br /> Date Issued Al?—t// <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 /> JOB ADDRESS AND LOCATION------------ � <br /> Phone `�- ' •• <br /> Owner's Name-------•------------------1A41-f/---`----�--�----�Q-•r-�---�^'--� - zer -------------------------------------------------------- <br /> Contractor's <br /> - 7 <br /> Address-------------------------------------- ( /' r <br /> --------------------------------------- <br /> Contractor's Name ------------------------------------------------ Phone_ r <br /> -- - -- � <br /> Installation will serve: Residence �A artment Hou7s� <br /> � ❑ Other-'[3 <br /> ❑ p Commercial ❑ Trailer Court [].-,Motel <br /> Number of living units: __ ___ Number of be( __ umber of baths //-Lot siz �__"_,z �:- <br /> -------)------------ <br /> Water Supply: Public system ❑ Community syste rivate jn Depth to Water Tab Q ft. <br /> Character of soil to a depth of 3 feet: Sand Ej Gravel ❑ Sandy Loam ❑ Clay Loam 0--'Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date___________________1 No ®`New Construction: Yes ®'No ❑ FHANA: Yes ❑ No ["' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted.if public sewer is available within 200 feet.)_ <br /> Septic Tank: Distance from nearest well_, ----"Distance from foundaf4__ 5�___f____Material---Fle ________-_ <br /> ❑� No, of compartments-----'.1�..._...---- -----Size---Ar—� _t .___Liquid­depth . Capacity --- <br /> Disposal Field: Distance from nearest well. �r Distance from foundation a ____._.._.Distance to nearest lat line_ -----:" <br /> 0x Number of lines--�"------ "--- ---------------Length of each fine. _/ -- �------- Width of trench.___--_9�--- -------------...r <br /> Type of filter material_ t t d _Depth of filter material___1rgV...___._.Total length___-___" --___`__._!-_ • <br /> Seepage Pit: Distance to <br /> [] nearest / IL__/4P_/_1ADistancefrm found_ ation___ -/"- .Dista`n�yc!e t_o�Dneepatren_s.t_.lot line_'__� <br /> _ i9Size: Diameter_Number of pits------1 "--__-__Lining material.- �! 9 <br /> r—, — r,W,_ �► <br /> Cesspool: Distance from nearest well-----------------Distance from foundafiion___________________Lining material__. ------------------------------ <br /> b <br /> ❑ Size: Diameter---------------t------------------ ----Depth.---------------------------------------------------Liquid Capacity----------------- ----------gals. <br /> Privy: Distance from nearest well'".*.------""__._.__""."" "_________Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot fine __----------_---------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing .-" � <br /> (describe):--" 1�_" <br /> --------------------------------------------------•------------------ ---------------------------------- -- -- - <br /> - -_.t. I----------------------- 4 --- <br /> fi ------- <br /> S i <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) t <br /> 9 ) - �'^ - -------low and/or Contractor) <br /> zl <br /> Title)-- <br /> ----- <br /> itle __-- <br /> (Piot plan,'showing size of lot, location of stem in relation to wells, buildings, etc., can`be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- ---- - -- --------------------- DATE <br /> /T <br /> REVIEWEDBY------------------------------------------ - ----- ----------------------------- ------------------------------------------- DATE <br /> BUILDINGPERMIT ISSUED------------- -----------------------------------------------•------------:------------------ ------ DATE------------------,----------------------------------------- <br /> Alterations and/or recommendations: 1 ------ ------- C�- ~ <br /> T-- ------- � -- ------- -------- - --- �: <br /> ------- C-------------------------------- -------------------------------------------------------------------------- <br /> ---------- ---------------------------------------------------- ---------------------------------x--- ------------------------------------------------------------------------------ --------- ------------ <br /> ---------------------------------------------- --------- ------------------------------------- <br /> ---------------- --- --- --------- -----------------...--•-------------------------------------------------------------- -- ----- <br /> FINAL INSPECTION BY: `�Y �-.- -- _ Date----- - <br /> SAN <br /> - <br /> OAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E.Hasdlon Ave. 300 <br /> _Wesf' ak Street 724 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy, California <br /> F.P.0 O. <br />