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----- FOR OFFICE USE: <br /> ----------------- --------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. ......... <br /> ----------------------------------- --------------------- (Complete in Duplicate) Date Issued <br /> ----------------! ----------- I 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 herein described. <br /> This application is made in compliance with Count Ordinance No. 549. <br /> e----.Jpj---------- -------------------_-------------------- <br /> JOB ADDRESS AN 'DCA ION ------------- <br /> Phone----------------------------------- <br /> - -- --------- ----------------- <br /> Owners Name- <br /> --- --- -----7 -------------- <br /> Address------------_---------------_-00A._­W_!�_ <br /> Contractor's Name-----A — I - ---------------------------------------------------------------------------------------------- Phone.-----------------------•---------- <br /> Ilin <br /> �a ---- 9 <br /> Installation will serve: Residence � partment House El Commercial E] Trailer Court El Motel El Other El <br /> --) V <br /> Number of bedrooms ___ Number of aths ,p -_ Lot size ----- I-------- <br /> Number of living units: --- e ------ <br /> Water Supply: Public system E] Community system El PrivateNumber <br /> to Water Table _4W_ ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] S y Loam Clay Loam [I Clay El Adobe B-14ardpan 0 <br /> Previous Application Made: ;If yes,date----------- --------1 No ff>oNew E] Clay <br /> Construction: Yes ET`5, D FHA/VA-. Yes' [« lO El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No Septic tank or cesspool permitted if public sewer is available within 200 feet.).- <br /> jon--- M f rlal_.cc-ff X-e- ------------ <br /> Septic Tank: Distance from-nearest we)L,_'M---------_Distance from foundation___ <br /> fh Capacity --- <br /> No. of,cornpartments----_3------ $X Liquid dep- -- ---------------- <br /> --------Size= /.r <br /> Disposal Field: Distance from nearest w0__4P___'1__.Distance��fro <br /> ioininclafion,/V---------..Distance to nearest lot line--X---------- <br /> Number of lines--------?rn----­---------------Length eac ie -- ------- - -_------Width of trench --------------- <br /> Type of filter of filter material-_-___ Total length-----%---- ----- <br /> Seepag Nf�: Distance to nearest well,/."I ----Distance from foundation./q/ <br /> ------------Distance to nearest lot <br /> Number of pits-----Z-__-------Lining material_y-_ac__A<—__. Size: Diameter-- _,Depfha,4 <br /> Cesspool Distance from nearest well-- _-_-___--_Distance from foundation------------- -----Lining material____._--__--__--__-.-_-----.--____-__. <br /> E] <br /> aterial-- ---------------------------------- <br /> E] Size: Diameter-------------------------------------Depth------------------------------- ----:---------------Liquid Capacity---------------------------gals. <br /> Privy; Distance from nearest well._.______---------- ---------------- ----------Distance from nearest building-._:---__-__-----____-__---_-_--_-_..._. <br /> ❑ <br /> uilding---------------------------------- --- <br /> F1Distance to nearest lot line- - ---------------------------------------------;-------------------- ------------------------ -------------------------------------------- <br /> Remodeling and/or repairing' (describe)--------------- - --- ---------------------------- <br /> --------------------------­------------------------------I---------------------------------------------------------------------------------------------------------- - --------------------------- <br /> ------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------- -------- ------------------ <br /> - <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------- <br /> I hereby certify that:I have r- aced this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, SfafeAr, <br /> —aW;Pand "I ,,andegulations of the San Joaquin Local Health District. <br /> (Signed)-------- ------ ------- ---- ---- - -------- - ------------ ---------- - --------==----------------------------- ----------------------------- ----(Owner and/or Contractor) <br /> By:------------------ ----------�(Title)­_g"111_�' _,e'X_�_ __ - ------------------ <br /> y --- --------- ------------- ------------------- <br /> (Plot plan. showing e of lot, location.of-s stem in relation o wells, buildings, etc., can be placed on reverse side). <br /> V FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- - --------- ---------------------------------------- -- -- -- -- - -- ------ DATE-------q- 27 - AV-------------------- <br /> REVIEWEDBY----------------- ----------------------- - - ----------------------------------------------------------- -- ------------ DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED-----------------:------------------------------------------------------------------------------------ DATE------------------------------------------------------------- <br /> Alterationsand/or recommendafions:----------------------------------------------- ------------------------------------------------------------------------------------------- ------------------- <br /> --------------------------------------------------------------------- ------ ----------------------------------------- ------------------ ------------------------- ------------------------------------------------ <br /> -------------------------------------:--------------------------------- ---------------------------------------------------------------------------- ­--------------------:---------------------------------------------- <br /> ----------------------------------- ----------------------------------------------- ---------------------------------- ------------------- -----------------------------I--------- ------------- - ---- - <br /> -------------------- <br /> -------------------------------------------------- --------------------------------------------------- - -----I-------------------------------------------- ------------;------------------ ------------------------------ <br /> FINAL INSPECTION BY:. -------------------- Date./_c....... ------------ -------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 13-S9 3M 3-'63 F.P.CO. <br />