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JOR OFFICE USE: <br /> - ------ ----- -------- - ---- -_ <br /> _7� ! ---------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued _P�cA:C <br /> 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 County Ordinance No. 549. <br /> JOB ADDRESS AND OC TION -------- ---&-lelt 4"0--- --------- <br /> -------- -- ---- --------------------- <br /> -------------------- <br /> Owner's Name------- ---- ---- -------------- ------- ---- --------- -- ---- Phonen�---------------------------------- <br /> 7 - ---------- <br /> ..... ....to ----------- <br /> Address-------U-3 ------ - ------ -- --- -- -- ---------------/ ---- ----------------- <br /> c c 4 <br /> ...... .. . . -- -- --- --- ---------- --------------------------_-------- Phone....__:_.-------------------------- <br /> Contractor's Name------------------------------ ....... ____021------tic. <br /> Installation will serve: Residence [] Apartment House [:] Commercial [:] Trailer Court W;Motel 0 Other <br /> ❑ <br /> -- <br /> Number of living units: -------- Number of bedrooms -------- Numberbaths - ----- Lot size -----------------------------------k------------------------ <br /> Water Supply: Public system E] Community system 0 Private ,7Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loam E] Clay Loam C] Clay Ej Adobe 5--`Hardpan 11 <br /> Previous Application Made: (If yes,date-----------:........) No E] New Construction: Yes E] No [:] FHA/VA: Yes El No 1771 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------- i <br /> El No. of compartments---------- ------------ Size--------------------------------Liquid cleph------------ -- --------Capacity---------------------- <br /> D;spjl�-Kield: Distance from nearest well__5�7_-_-_Distance from foundation----- Distance to nearest lot line_________________ <br /> Number of lines----------- Length of each line---------'94P.-I-- -__-___-Width of trench-____c;2____,_ ------------------ <br /> Type of filter material--- ------ Depth of filter. material------/-f-----------Total length-------- ----------------------- <br /> See Pit: Distance to nearest well---- r------Distance from-foundation---.__1 --`_Distance to nearest lot line---- ------ 11 <br /> Number of pits------- .f—-------Lining material-------ZZAK�-c-_-'Size; Diameter-_____A/,f_`*----- Depth---- ----- -----j. 0 <br /> Cesspool: Distance from nearest well_________________Distance from foundation--- --------------- Lining material_____--_____________-_________-______. <br /> ❑ Size; Diameter------------ -------------------------Depth--------------- ---------------- -------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well------------------------------------- ----------'_Distance from nearest building_______________________________________. <br /> ❑ Distance <br /> uilding----------------------------------------- <br /> Distance to nearest lot line------------- ----------------------- ------------------------I--------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe}:------ --------------- ------------------------------------------------------------------I------------------------------------ ----- ------ <br /> --------------------------------------------------------------------------- ------ --------------------------------------------------I-------------------------------------------------- <br /> ------------- __4 <br /> ---------------------------------------------------------------------------------------------- --------------------------------------- --------------------------------------------------------------------- <br /> ------------------------------------------------------------­-----------------------------------------------------------------------------1------------------------------------------------------------------ <br /> I hereby certify that I have prepared this application rind that the work will be done in accordance with San Joaquin County <br /> ordinances, State&11 . and and regulations of the San Joaquin Local Health District 9 <br /> (Signed)-------------- ---- - ---------------------- - - -( --------- -- -----------------------------------------------------------------------fj!R!ffwand/or Contractor) <br /> BY- . .. ... <br /> ...... --- ---- <br /> --------------------------------------- ------------- ---- <br /> ---------------------------------(Title)--------------------------le)--------------------------- <br /> (Plot plan, showing size of lot, location of system in relation, o wells, buildings, etc., can 6e placed on reverse'side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- - --- ----------------------------------- DATE------ 0 --------------------------- <br /> REVIEWEDBY-------------------------------------- -------------- ------------ ---------------------------------------------------------- DATE-------- ---------------------------------------------- <br /> 'BUILDING PERMIT ISSUED------------------------------------------------------------------------•------------------- ----- DATE----------- ---------------------------------------------- <br /> It rations an /or tion: /Z x <br /> r corn s:---------- 7�. __f� -----------c <br /> ------------------------------------------------------------------------------ -------------- <br /> X04 <br /> ---------------------------------­­­--------------------------------- -------------------------------------------------------------------------- ----------------- - ----------------------------------------------------- <br /> --------------------------------- ---------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------­ <br /> --------------------------------I-------I----------------------------- ----------------------------- ---------------- ----------------------------------------------------------------------- -------------------- <br /> FINAL INSPECTION BY:-. . ..... .. Date__.-_____- -------------------------------------------- <br /> 1���S>AN J0___AQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxellon 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 8-59 31A 3-163 F.P.013. <br />