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FOR OFFICE USE: <br />----- ---------------------------------------- ------ APPLICATION FOR SANITATION PERMIT Permit No. <br /> - - --- ----------------- {Complete in Duplicate) �� <br /> ----- ---------- <br /> ----------------- <br /> ------- <br /> ---------------- -- --:- Date Issued __-... - <br /> - <br /> ------------------------------------------- <br /> -------------- This Permit Expires 1 Year From Date Issued , <br /> Application is hereby made to the San Joaquin Local Health District for a permifi...oxcors#-uct-and-rinstall the work herein described' <br /> This application is made in compliance with County Ordinance No. 549. ^ f ; <br /> __---_. - ' <br /> �---w- <br /> G - v <br /> --------JOB ADDRESS AND LOCATIO ------ -- Pho'ne------4'-y-- <br /> _---- a <br /> Q - <br /> Owner's Name..--- --------• -------- - " <br /> ----------•----- I----..---. <br /> 1--3.7 <br /> Address ----------••------- ---------------O• 7 &?. <br /> Contractors Name ___ _ -- - � - . <br /> I <br /> Installation will serve: Residence. K Apartment House [3 Commercial F] Trailer Court ❑ Motel C]' Other ❑ <br /> Number of living units: _II___ Number of bedrooms -c?.- Number of baths _/_ Lot size ->QQ..Q <br /> rWater Supply: Public system ❑ Community system [:] Private Depth to Wa ,Table .-ft. <br /> '^ r """" " Cl Adobe Hardpan ', <br /> -ICharacte� of soil to a depth of 3,feet: San El Gravel ❑ 5and;1EoamZ Clay Loam r y ❑ ❑ I] <br /> Previous Application Made (If yes,date--- ---------------]a No ❑ New Construction: Yes E] tNoX FHA/VA: Yes ❑ No ❑a ,� <br /> TYPE:OF INSTALLATION ANDSPECIFIC'ATIONS: <br /> (No, es ptic-tank.or cesspool permitted if public sewer is available:within 200 feet:)' > ,� <br /> ep ' arPic4 Distance from nearest well----------__----Distance from foundation_______ __________Material__-----._._._________ ..____-__..____'____.____: <br /> of compartments--- ---------------------Size------------------- i - -----Liquid!de, <br /> Capacity ---- <br /> No. / r <br /> :a } s d Distance to nearest lot <br /> +, Disposal Fdlcl: Distance from nearest well 6- -------Dif <br /> istance from foundation___ _ ___________ <br /> Number of lines____ ____ _______ Length of each line_ �� g f <br /> 0_ <br /> Type of filter material- �. f _Depth of filter materiaL__._�1�___._----Total length _I- `-- <br /> Q(�._ -__ ___-_._ Width of trench__.. <br /> Seepage Ph: Distance to nearest well ____________________Distance from f}ound5tion____--------..---.Distance to nearest lot line___-___.___-- -- <br /> ' Size: Diameter. De Dept <br /> I Number of its---------------- ----Llning material---------- ---_3 __-- P { <br /> ❑F p <br /> Cesspool: s Distance from nearest well--------------_Distance from foundation__.'________________Lining material----------------------__________._:---- <br /> Size Diameter-- -------{ # --- - ------ Depth--- $----- ------- ---------------Liquid Capacity--------- ---- - gals <br /> Privy: Distance from nearest building-_ <br /> t DEstance.from nearest well �: g = f j. <br /> ❑ Distance to nearest lot line.----_.. - ------------------------------------------------------------------------- <br /> Remodeling and/or repairing [describej:_.. -- - -- --------------- <br /> . - ----- - --------- - -- ----------------•------------------------ <br /> !s 1 ' <br /> I a- <br /> --i------------------------------------------------------- ---------------------------•---------------------------------------•--•-----------------------------------------_---- <br /> ----------- <br /> ------- ----- <br /> ------- --- ---- ------ ---------------------------------------------------------------------­---------------------------------- ' <br /> I hereby celfify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Statbq 'ws, and rules and regulations of the San Joaquin.,Local,Health District. <br /> —„ -.. <br /> wnet•and/or Contractor) <br /> (Signed)-------- <br /> By:__! <br /> ------ —� <br /> By:.-•--'---------- L----- ----------------- ter ------------ -------------------------------------- ----------------- <br /> (Plot plan, showing size of,lot, location of system relation to wells, buildings, etc., can be placed on reverse side). <br /> + FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- +:,--------------- --- DATE__._.____--_--- -- •-- <br /> - -- <br /> ------------------------------------ <br /> REVIEWED .BY------------- +- - - �- DATE-------------- <br /> BUILDINGPERMIT ISSUED---------- --------------------- ------------------ DATE.----------------------------------------------- ,--------- <br /> Alterations and/or recommendations----------- -------- ---------- ---------------------------------------------------------------------•----------------------------•-------------- = ---------- <br /> - <br /> -------------- -------------------------------------------------------------------------- -------------- ---------- <br /> ------------•----------------- ------------------------------------------- ------- <br /> ------------------------------------------------------------------------------------- <br /> ----------------------------- ---------------------------- --------- ------------------------------------- <br /> ------------------------ <br /> ------------- <br /> 4. <br /> -_____________________________________________________________________________________ ______._____.__.__.___ <br /> � F <br /> FINAL INSPECTION BY:---------_- --- •---- Date <br /> -------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxelton 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 9-59 3M 3-•63 F.F.DD.' <br />