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R OFFICE USE: <br /> -— <br /> -- -------- <br /> -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. <br /> - <br /> ---------------------------------------------------------- (Complete in Duplicate) <br /> - <br /> ------------------------------------------------- This Permit Expires I Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549, <br /> JOB ADDRESS AND LOCATIONA/-alve:t�, -- <br /> --- <br /> -------------- ----------------------------------------------------------------------------------------------------------------------------- <br /> Q. <br /> Owner's Name--- ---- ----- ... . ........... ......... --------------------------- Phone------------------------------------ <br /> -----------------------I------------------- <br /> Address-------- <br /> ---------- --- <br /> ----------------_- ----------------------------------------------------------------------------------------- <br /> Contractor's Name--- --------------­----- ------I--------------------------------------------------------------- ------ ------ Phone----------------------------------- <br /> Installation will serve. ;Residence ErApartmerif House El Commercial El Trailer Court F1 Mofpl E] Other <br /> Number of living units: ___/___ Number of bedrooms _2__ Number of baths _1---- Lot.size ----0�7q__ -----------/00-/ <br /> --------------------­------- <br /> Water Supply: Public system E] Community system E] Private n6`epfh to Water Table,_q-- ft. <br /> Character of soil to a depth of 3 fee't: , Sand F-] Gravel [] Sandy Loam 0 Clay Loam 0 Clay E] 'Adobe 8--Hardpan E] <br /> Previous Application Made- (If yes,fdate--------------------) No 91--lNew Construction: Yes Er-N-o F-1 FHA/VA: Yes F] No n- <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspoolpe 4 rinniffed if public sewer is available within 200 feet.)-- <br /> Septic Tank: Distance from.ne'arest well�.........Distance from foundation_/A_------------Material__7/*�R-------------------- - ------ <br /> C <br /> -------------- t7gpz� <br /> No. ments-.--',-7—-----------------Size------3- Liquid dep.fh----:�---- Capacity.--.------------ <br /> of comparf <br /> Disposal fiield: Distance from nearest well..._---__Distance from lZurIZ line-111Y V..... <br /> Number of lines-.-.-.-j------- -.Length of each ---------------Width of french.-4.......................... <br /> Type of filter Depth of filter'mpterial--le_-�------------Total length----2- ------------------------------ <br /> Seepage P& Distance to nearest wellAV-------------Distance from founclation-ZIP.............Distance to nearest lot line­,.-:�-�-J--- <br /> Number of pits-______'_I___________-Lining maferial_��10C�------Size: Diameter___ -._-____..Depth_9Z__y 7—------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from-fofjndati0' n____'A-'11__o---------..Lining material--_-___}._____-__-_____.- <br /> El Size: Diameter---------------------------------------Depth--------------------------------------------.--------Liquid Capacity-----0---------------. ------gals. <br /> I 1 -1 <br /> Privy:. Distance from nearest well-_______________ ------------------------ -----—Distance from building,-------------N'A- ------------------------- <br /> F1 Distance to nearest lot line.... --------------------------------------- r°� � <br /> -------- II , <br /> - --------------------------------------------------------------- ---------------- <br /> 4— <br /> Remodelingand/or repairing (describe):--------------------------------------------------------------- -----------------------------------------I--------------------------------------­------- <br /> --------------------- ----------------------------------- P <br /> I----------------------------------------- I . I <br /> -------------------------------------------------------------------- ------------------ ----------------------- <br /> -------------------------------------- ----------------------------------------------------w-------------------------------------------- ------------------------------------------­------------- <br /> i i <br /> ---------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------- -------------------------------- <br /> I hereby certify that I have prepared this application and that the worVwill be done in accordance with San Joaquin County <br /> ordinances, State laws' and rules and gula ons of fh6 San Joaquin Local Health District. I <br /> (Signed)----------------------------------------------- ------- ----------- -- -------------------------------------------I---------------------------------------------(Owlr and/or Contractor) <br /> By:------------:----------- ------ - - - ------------ ----------- ------------------------------- --------(rifle)---------- ---------------i----------------- ------------ - <br /> [Piot plan,-showing,size F <br /> ,and <br /> syste in relation to wells, buildings, etc., can be placed on reverse side). <br /> J <br /> FOR DEPARTMENT USE ONLY <br /> ------------------------- <br /> ------------------------ <br /> APPLICATION ACCEPTED BY--------- ----------------------- VS--------------- --------- DATE----------L <br /> RCVIEWED BY------------------------------------------ -- ---------------- ---------------------------------------- DATE <br /> i <br /> -------------------------------- --------------------------- <br /> BUILDING PERMIT- ISSUED.-------------- ---------I---- -------------------- DATE--------- !-----------------1 <br /> ------------------------------------I----------- ------------------------------- <br /> Alterations <br /> ---------------------------- <br /> f <br /> Alterations and/or recommendations---------------------------- <br /> :----------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------I-------_------------------------------------t <br /> -- --------------------------------------------------------------------------- ------------ ------------------------------------------------------------------ <br /> ----------------- --------------------------------------------I- I I I <br /> ------------------ --- - --- ---------------------- ------------------I <br /> ---------------------------- <br /> ------------------ ------------------------------•--------------------- --------------------------------------------------7=-------------------------------------- ----------m------------------------------------ <br /> --------------­- -----------­------- - ------------- ------------------- -------------------------------------------------------------- ­­---------------------------------------------- -------------------------- <br /> FINAL INSPECTION BY--------------- . ..... ------------ ---------- Date--------- -- ----------- <br /> - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.maxelton Ave. 300 West Oak Street 724 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy, California <br /> ES 9 REVISED 8-59 31-L 3-'63 F.F.00. <br />