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FOR OFFICE USE: <br /> -------------------------------------------------------------------------------- <br /> APPLICATION SANITATION PERMIT Permit Z- <br /> ---------- <br /> ------ W <br /> ----------------------------------- \61 (Complete in Duplicate) Nte a <br /> ----------------- <br /> - It I s s u'd �A�Avo <br /> ------------------;------------------- -- -------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for h permit to construct and install the work h&ein described. <br /> This application is made in compliance with County Ordinan No..,549. <br /> ATION_ <br /> ;------------------- --_----- <br /> JOB-ADDRESS LOCA ­ ------------------------ -------------- <br /> --------------------- -- Phone------- ---------------------------- <br /> ------------- --------- <br /> Owner s Name- - -- ---- <br /> --•-----------------------••-----•----------------- <br /> Ad d ress-------------- j L.)9Z R.q1 ---- -------- -- <br /> Contractor's Name--------------------------------------- <br /> --------- Fihone---------------------------------- <br /> Installation will serve: Residence [D Apartment House 'C8mmerciol [3 Traijer- 0 t 0 Motel El Other <br /> T <br /> .s <br /> umber of bedrooms Number of baths <br /> Number of:livi -t N ths --- 0; e ---------------_--_-- <br /> �usn I f <br /> c y t & Depth' o Water Table <br /> Water Supply: Publi em E] Com�ni]jnity system El Private 0 ff.7eell' <br /> Character of !soil to a depth of 3 feet:� Sand E] Grave[E1.4' Sandy Loam D e --la Loam F-1 Clay Adobe [] Hardpan <br /> 4 %,�;, <br /> Previous Application Made: (if yest,d6te----- -------------) ❑ <br /> 1, No.�v i"New Co" nstruction:.,,Ye No E] FHA/VA: Yes ❑ No E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic'f aiiik-6r cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-16P--------Distance from founda,flon,/_e)!--------Maferial-- ------------------------------------------- <br /> -- <br /> j- <br /> No. of compartmenfs..___,;?--------------- <br /> k_,,7__Liquid.depfh----- --- - --------Capacity-/,"Zo--- <br /> X 'we Z-`.._____-Distance,from foundation_---ation---- ---40, Distance to nearest lot ---------- <br /> Disposal Field: Disfance-fromne6re-st- <br /> rc 1-1,9, <br /> M fe <br /> Number of lines-- ----------- ------ Length-6f, each hne_ ��_/4�Width of french------ -------------- <br /> Type of filter material__ -1 .__Depth 6f,'filter.,material--- ----f------------Total length----- --- ------ ---------------- <br /> _ A <br /> Seep a Pit. Distance to nearest well---/.,,!�,0__`_Disfanc m.fo hd 'on.__- Distance to nearest lot line-----S------ <br /> ---------- <br /> ---------- <br /> Number of pits------V-----------Lining material-- ---Size; Diameter._41-00------ Depth----- - -----••-----_---- <br /> Cesspool: <br /> epth-- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_---__--.--.---.-----_--.---_-__---.-. <br /> ❑ I Size: <br /> aterial------------------------------------- <br /> Size; Diameter---- --------------------------------Depth----------------------------------------------------Liquid Capacity---.----------- --------gals. <br /> P_rTv Disfanc; f�o_m-nearest well--'-7'-'-- i't`ance­fFo__rn nearest. ------------------------------- <br /> y: <br /> F1 'Distance to nearest )of line--------- ---------------- ------ - -----------:�-----------------------f <br /> --------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe):------------------------- --------------- ---------------_--•-------------------------------------------------_---------------------------------------- <br /> I -------------- <br /> ---------------------------------------------------------------------------I---------------------------------- ----------------------------------------------------------------------- -------------------- <br /> ................ <br /> --------------------- ---•-•----------------------------------------------------------------------­­-------------------------------------------------------------------- <br /> ------------------------------ <br /> --------------------------------------------------------------------------------------------------------------- •----------------------------------- ---------------------------------------------------- <br /> I hereb certi that I:have prepared this application and that the work will be done:in accordance with San Joaquin County <br /> ordinances ate ws, and rulon d-i u a ions <br /> 1 fi of the San Joaquin Local Health DisfriZt. <br /> 9t <br /> e <br /> (Signed)----- - ------------ -------------- ---- ---------------------- ---I---------411 •-------------------------------6-------------- .__(O ner and/or Contractor) <br /> -------------- <br /> By:---------- -------------_A ---- ----------------- ------ --1----------------- --------- --- ------- <br /> (Plot plan, showing size of lot.'I;ca+ion of system in re la on to wells, buildings. etc.. On_be placed o reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------ <br /> --------------------------------------------------------------------------------------------- DATE---------- �----------------------------- ----------------- <br /> REVIEWEDBY--------------------------------- -- -- --- - -------------------------------- -I--- --- - - --- -------- --------------• DATE------------ ---------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------ -- ------------------------ DATE--------------------------------------------- <br /> Alterationsand/or recommendations:---------------------------------- -------------------------- ----------------------------------------------%------------------------------------------ <br /> ----­---------------­_­------------------------­-­------------------------------------------------------------------------:--------------------------------------------------------------------------------------- <br /> ---------- --------------------------------------------------------------------------------------------------------------- ------------------------------ ----------------------------------------- ------- ------ <br /> --------------------------------------------i------I--- -------- ---------- I---------------------I---------------------------------- -____1_1--------------------------------------I----------------------------- <br /> --------------------------- ------ ---------------------------------- - ---- -- - ------- ­---- --------------------------------------------------------------------------------------- ----------------------- <br /> -- ------- -INSPECTION BY:----------/ ----- -------------------------- Date-------- -- - ---------------- ------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California A Manteca,California Tracy,California <br /> ES 9 REVISED B-59 3M 3-'63 F,P.CLI. <br />