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FOR OFFICE USE: <br /> "APPLICATION FOR SANITATION PERMIT Permit No. <br /> OFFICE <br /> ------------------------------ <br />------------------------------------------------ -------- (Complete in Duplicate) <br /> 1 1. Date Issued <br />---------------------- ---------------------- This Permit fff2ires 1'Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct and install the work herein. described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> ------- --------------------------------------------------- ------------------------------------ <br /> JOB ADDRESS AND LOCATION------ -------- ------------------- - - - <br /> ------ 4L <br /> Owner's Name--- --- - ------------------- ------------------------ Phone...... <br /> --------- ------------------------------------------------------------------------------------------------- <br /> Add ­ --------- <br /> -------- <br /> ------------------------------------- <br /> Contractor's Name--------------G -------------- --------------------------------------- -------------------------------------------.1 Phone.......... ------------------------ <br /> Installation will serve: 'Residence [Ir"!.�Apartment House E] Commercial E] Trailer Court [3 Motel E] Other 0 <br /> Number of living units-_A7n Number of bedrooms _jZ% Number of baths __A__ Lot-"size __77,5rx.1.6-0--------------...... <br /> Wafer Supply: Public -system Ofl--community system El Private E] Depth to Water Table ff. <br /> Character of soil to a depth of 3 feet :Sand 0 Gravel'El Sandy Loom [j Clay Loam El Clay El 'Adobe C- iarclpan 11 <br /> Previous Application Made: (If yes,date--------------------Y No P!rNew Construction Yes [ o E] PHA/VA: Yes E] No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool perlm iffed if public sewer is available within 200 feet.)/ <br /> 4 - 1 <br /> Septicj-ank: Distance from nearest welle2lo-ArP------Distance from foundation__ jP.............material------ <br /> No. of comparfments__.__;1___.__ :----------Size------4-X-4721-_9----Liquid clepth----------17'.:-----------Capacity <br /> ------------lr­ <br /> Disposal Field: Distance from nearest,rest well-7za_—_?._._.Distance from foundation___3jO----------Distance to nearest lot line_._____________._of lines__________________________________- I Length of each line-----7-0 ____..______.Width of trench___----_----Z k................ <br /> Type of filter mafe'rial--- ---------Depth of filter material---/,?--*-----------Total length.............rio------------- -----__ <br /> Seeps Pit: Distance to nearest well__47WA4------Distancej <br /> .5om f d ti -------------Distan�e to nearest lot line __.____._....Fun a ton-'36 tr <br /> Number of pits.__.________________ ____31-----------Depth--------- ---------- <br /> - Lining material---- Size: Diameter <br /> Cesspool: Distance from nearest well----------------'Distance from foundation------------------- Lining material______._________________________-__-- (�,`I <br /> ❑ Size: <br /> aterial------------------------------------- <br /> Size: Diameter---------------------- ------.Depth------------------------------------ ---------------Liquid Capacity-------------_------------gals. <br /> Privy: Distance from nearest well--------------------------------------------------Distance from nearest building------------------------------- <br /> 0 Distance to nearest lot line---------------------------- ----------------- ------------------------ -------------------------------------------------------- <br /> Remodelingand/or repairing (describe):----•---------•--_----�----- -------------------------------------------------------------I------------------------------------------------------------- <br /> ---------------------------------------- ---------- ----------------- <br /> ----- ---- ------- --- --------------------------------------------------------------------------------------- <br /> -------------- - <br /> ---------------------------------------------- <br /> ------------------------------------------------ ......... .................I— -- ?��-------------------- <br /> ------ ---------- ------------------ <br /> ----- ------ ------ ---------- <br /> ------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------ ---------- -_-----•--- <br /> I hereby certify that I have prepar6d this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws-, and rules andireriat7' "s of the San Joaquin Local Health District. <br /> . <br /> (Signed)­--------------- ----------- ---- ----- ----- ---------------------------------------------------------------------------------(Owner and/or Contractor) <br /> ---- ----------- ---- <br /> By:-----------------------------------% ----------------- -------------------------------------------------Title-------------------Z--------------------------------------------- <br /> (Plot plan, showing size of lot, location' ;f system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY. . ..et..,. : DATE <br /> /--------------------------------- <br /> REVIEWEDBY----------------- ------------------- ------------------------------------ ------------------------------ DATE__ ------------------------------- <br /> BUILDINGPERMIT ISSUED--------------------1---------------------------------------------------------------------- ---1­1. DATE------------------------------------------------------------- <br /> Alterations and/or recommendations----- --------:------------------- - --- -------------------------------------------------------------- -••----•------------------------------------ <br /> ------------ <br /> ----------------------------­- -------------------------------------- ---------------------------------------------------------------------------------------- ---------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------- ---------­-------------.._.__..._......--_._..__...--------•------------------­........I.................. <br /> I I <br /> ---------------------------------------------------------------- ------------------------------------------------------------ ------------------------------------ ------------------ --------------------------------- <br /> ------------------------------------ ------------- --------------------------------------------I---------*--------------r------------------------------------- ----------------------------------- <br /> ----------------------a­ ----------------------------- <br /> FINAL INSPECTION BY:.----- Date <br /> ----- ------------,----------- ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 730 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ss-9 Rrviero 8.s9 F.P.M 2hi 6-60 <br />