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FOR OFFICE USE: <br /> .......................... ........................... <br /> ---------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. <br /> .............. ................................-------- <br /> (Complete in Duplicate) 4 <br /> .....................Z�------I------ ...... I <br /> "I Date\lssued ....j <br /> This Permit Expires 1 Year From Date Issued <br /> NApplica-tion is hereby made to the San Joaquin Local Health District for a permit to construct N t—T RE -sVX-1l`?work herein des(zdWL <br /> This application is made in compliance with County Ordinance No. 549. <br /> 4 <br /> !t <br /> JOB ADDRESS AND ATIO ... .... ........... <br /> x <br /> ... . ...... <br /> IL <br /> • es <br /> --- - ---- - --------- ------------- <br /> Oviner's Name.-------- <br /> - -------- ----­----------- - ---- - --------- ................ ...... ........................ ----------------- Phone.....�v . .... <br /> Acldress---------------------- ... <br /> ---------7e� <br /> ................................................................................... <br /> %. . .... -----•-.--•-f••--••-••••......--- <br /> ....... .. '�l <br /> ,Contractor's Name........ ...... . ...... -------- ft- ----- -------------f.......................................................... Phonlb .�.Z_ !9Ve <br /> * I' ... V - <br /> Installation will serve: Residenc Apartment House [-] Commercial rl Trailer Court E] Motel [I 'wbther ❑ <br /> 79 0 <br /> ,1� Number of living units: . ..... Number of bedrooms 2--- Number of baths ---/_ Lot size ---4�1 ....t�­ -------- ...... <br /> • Water Supply: Public system [-] Community system [3 Rrivate'10'f'^ ,ep <br /> Dth.to.Water.Table/.P. ft. <br /> iI <br /> 'Character of soil to a depth of 3 feet: Sand [] Gravel E] Sandy Loam E) Clay Loam [:] Clay E] Adobe OA96'rdean <br /> 4q <br /> 40Previous Application Made: (if yes,date-----------!........) No El New Construction: Yes El No FHA/VA: No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Tank:ep t6nk: Distance from nearest well...............'Distance from foundation.................;..Material................................................. <br /> No. of compartments...........................Size....................... ....:...Liquid clep�'th.............I <br /> .............Capacity....................... <br /> Disposal field: Distance from nearest well.4 -------Distance from foundation.... .. ----�_._Distance to nearest lot line/ppp., <br /> Number of lines........�.­, Length of each .......Widthtof trench...._..c ........ <br /> Depth of filter rn ate <br /> Type of filter.mat <br /> erial._-55 _'D terra(. If........Total length-.-.................../15. ...... <br /> Seepage Pit: Distance to nearest-well--.-------------------Distance from foundation....................Distance to nearest lot line----_--__---_-_ <br /> } ❑ <br /> ine------------_-- <br /> F-I Number of pits......................Lining material.................._.Si2e. Diamefbr.....................Depth........... -------_------ <br /> Cesspool- Distance from nearest well.................Distance from foundation....................Lining material_---_-_----.--..-_-_----_-_.._....-_.. <br /> Size: Diameter----- ........ ----------------------De th-----------------------------------------------------Liquid Capac�ity---------- -----------------gals. <br /> 0 <br /> Privy: Distance from nearest well--.--- --------------------------------------.-D7stance.from nearest building___-_...........................__...__... <br /> Distanceto nearest lot line...-• --_---------_............................................................................................. ------------------------- <br /> Remodeling and/or repairing (describe}:....e5?_4_ ------------------------------------------------ <br /> ................... .. ........ <br /> . .................... .... ...... <br /> ----------- ------------------------------------------------------------------------------------ ..... ..... ... <br /> ............................. .................................................................................................._..................................................................­­-------------------- <br /> -----------------1---------------------------------------------------------- --------------------------------------------------------- ---•--•---•---•-•----------- ................................................. <br /> A I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, St5"ws, and rules and regulations of the San Joaquin Local Health District. <br /> . ......A....... •... .... ------------------------------------------- wrier and/or Contractor) <br /> 'I..... . ---------- --------- <br /> itle --------- ...................................... <br /> By:� ...... --_-------- ------_------------ <br /> ........................ ........ <br /> (Plot plan, showing size of lot, location of system in re on to wells, buildings.,etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY...................... /L------/- =-------------------------- <br /> DATE...............�A- -------9---/4-xx------------- <br /> REVIEWEDBY------ .......................................... ------------------- ..... .... -------------------------------••••. DATE.............. ..... __......../................ <br /> BUILDINGPERMIT ISSUED-------_--------- ....................................................................... --------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations:.................. ---------------- ....... ------------------------------------------------------------------------------------------------------------------ <br /> ................................................................................. <br /> .........................................­..................................... ...........................................­............ <br /> .............................. .......................................................................................­­................ .................................................................. <br /> ..................................... .....................................................­­­.......................................................................................... -------------------------------- <br /> ....................... ....................................................................................................­...................... ------- ......... ........... ..................................... <br /> FINAL INSPECTION BY:............... ----- Date--- -------­------ ..........ID......... -­---------------------...... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hamllon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> Ess 9 REVIMED 8-59 3M 3-'63 F.F.00. <br />