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FOR OFFICE USE: <br /> --------------- -------------------- - ------------------ APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------------------------------------------- ------------- <br /> 4 /A, <br /> -- ------------------------------------------ ----------- (Complete in Duplicate) —, <br /> Date Issued LAP/ <br /> ---------- Issued--------- -- --------------------- ---- ........ This Permit Expires I Year From Date Ised <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein des;ribed. <br /> This application is made in compliance with County Ordinance No. 549. A6j 0 ts— o Y 10--0 2-- <br /> JOB ADDRESS AND LOCATION-- 2 <br /> Owner's Name.----- - - --- ------------------------------------- ------------- <br /> -------------- <br /> Phone---------------------- <br /> 4`72 ---------------------------------------------------_----------------....... <br /> Address----- ------ ........ --- ---------------- <br /> Contractor's Name- - ------ ----- <br /> --------------------- ---------7 <br /> Phone__-------------- ---- <br /> - <br /> Installation will serve: Residence Apartment House E] Commercial Ej Trailer Court Ej -Motel E] Other E] <br /> Number of living units: Number of bedrooms —3-- Number of baths Lot size -------------- <br /> ------ . . ...... <br /> Wafer Supply: Public system ❑ Community system ❑ Private,, [Depth to Wates Table -------- ft. <br /> Character of soil to a depth of 3 feet: -Sand-E]- -Gravel E3--Sand'L:o`am�5?1,5Cbay Loam ❑ -Clay ❑E]-- Adobe[-] Hardpan E] <br /> y <br /> Previous Applicatidin Made:- (If yes,daW--- ---------------) No E] New Construction: Yes E] No E] FHA/VA: Yes 0 <br /> No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS. <br /> -(No septic M4 or cesspool pel rmi'4ed if public sewer is available within.200 feet.) <br /> k', I I I' /e7 <br /> as " - t e frpm f dat'o -----------------M f ------ <br /> Septic ar)k:__ _Distance-from near well------k0----D lsTa n--- <br /> r —C. <br /> oyn I a ria <br /> l--- <br /> "&I-':�y_,VS-Aicluid depth-----WP.--------- <br /> ...............Capacity__1'.,t06_ <br /> D;spo Field: Diltance from'ne'arest �welj----- 'Distance from foundation----J49�1_--Distance to nearest lot <br /> E!Kl �'V% Number of lines--------- - - ------Length of each . ...........Width of french'._._,-,Z_/------------------ <br /> Tye of-filter mlfbrial­ ,..---Depth,of filter ma-ferial--.-.---/Y--tf--,.Total lengfO---lia-0----------------:_i...... <br /> Seepage--Pit- Distance to neariest�\�el0l!-------------------Distance from f6unclation--------------------Distance to nearest lot line__...._.-::-_-..- <br /> .. t I--- i--------Size: Diameter-________ ______Depth---- ------------ <br /> El Number of"pits__-------------------Lining rriater-ia - ------- - -- ------------- <br /> s <br /> Cesspool: Distance from nearestwell_____._______________Distance Vom foundation, __.... ..___..._..Lining maferii1___. ,.___" <br /> spqo --------------------------- <br /> - <br /> Liquid Capacity---------------------------gals: <br /> El Size: Diameter----- ------- -------------------Depth------------------------------ --------------------- 7 <br /> Priv Distance from nearest well--------------------------------- ----------- ---Distance.from nearest building------------------------------- .�j-------- <br /> y: <br /> F1Distance to nearest lot line-------- ---------------------------------------------------------------------------------------------------_------------------------_...... <br /> Remodeling:and/or repairing (clescribe):�0-----T__-------------:--------------------------------------------------------------------- ----------:------------- ---------------- <br /> -------------------------------------------I-----------------------------k--------------------- ------------------------------------------------- --------------------------------------I--------------------------- ------ <br /> ----------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------- ---------- <br /> ---------------- -----------------------------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 regu'lations of the San Joaquin Local Health District. <br /> ri <br /> (Signed)-------:----------- --- - ----------- -------- -------------- ------- ------------------------------------------------------------------- C9F and/or Contractor) <br /> By:-------------- -- -- -- -------------------- ----(Title)----- ---------------- ------------------- ................. <br /> (Plot plan, showing size of lot, location of system in relation f0i ,.we buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED - -- ---- ------------------------------------------------------- DATE'-.-3Z_—("-_Y_ ------------------------------ ------- -P <br /> REVIEDBY----------------------------------------- -----------------------------------------------------------------------------I------- DATE----------------------------------------------------------- <br /> BU IIWEG PERMIT ISSUED--------------------------------------- - ---------------------------------------------------- DATE------------------------------------------------------------- <br /> - ---- <br /> --------------- <br /> Alterations and/or recommendations:___.---------- ------ -------------------------------------------------------------------------------------------------------­*------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------I——----------------------------------------------------------- <br /> ---- --------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------:--------- <br /> ------------------ ---------- --------------------------------------T------------ ---------- <br /> -------------- ------ -- -------------------------------------------------------- -------------------------------- <br /> --------------------------------------•--•---------- --------- ------------------------------------------------------------------------ ----------------------- ------------------------------------------ <br /> ---------- <br /> FINAL INSPECTION BY.i - ------------------- ------- -----------------------I-------- <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 Manteca,California Tracy,California <br /> ES 9 REVISED B-59 3M 3-'63 ;.P.CO, <br />