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-- -------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. <br /> -------------------------- --------------- -------------- (Complete in Duplicate) <br /> --- -------- -------------- --- This Permit Ex Dires I Year From Date Issued Date Issued -_-----_—------------- <br /> 2,153— 3 zq <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> This <br /> application is made in complia4ce,with County Ordinance No. 549. described. <br /> JOB ADDRESS AND LOCATION.;--j <br /> j------ ----------------- <br /> ---------- -------------------- <br /> Owner's Name ---------h-------------I w-------A&rr----------------------- ------- --------------------------r------------------ Phone- <br /> Address. <br /> -f-t------(-------- -------------------............ .............­---------------------------------------------------------------------- <br /> Contractor's Nam&' rv, <br /> kA­--�------------------------------------------------------------ ------------------ Phone <br /> Installation will serve.,-,,,1�Residence [s apartment House [] Commercial F1 Trailer Court E] Motel Ej Other <br /> ❑ <br /> Number of livingl,,units: _--/--_ Number of bedrooms -------- Number of baths -------- Lot size _-----.---"----------------- <br /> I 'Supply. Public system El Community system [] Private �bepfh to Wafer Table ------ ft. <br /> Character of soil to a depth of 3 fet: Sand 0 Gravel E] Sandy Loam E] Clay Loam L <br /> P. e ❑ Clay 5j---Adobe [-] Hardpan <br /> Previous Application Mad&.: (If yes,date... ----------------) No [�tNew Construction Yes <br /> I [ii�o El FHA/VA: Yes Ej No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank orcesspoolpe,'rmiffed if public sewer is available within 200 feet.) <br /> Septic jAnk: -1 f e <br /> Dista�ce from nearest welfl§_6 Distance from founclation--l'67--­----Mat riaf P0C <br /> No.,,of compartments-----------D------ -.--Size------>s ---------- ........... <br /> -------m---Liquid depjh­--!!-?---------------Capacify­/Z)CX1 <br /> Disposal Field: Distance 11 ---------------- <br /> Disposal <br /> �tance from nearest well Distance from foundation---9?0 to nearest lot line----------------- <br /> 12 N6mber of iinesJ--------V-------------- ----Length of each line----------?00------------ Width of trench------- <br /> ------ <br /> ----- --------- <br /> Sy <br /> T�pe of filter material 4-Rock ---Depth of filter material----/1?-7- -----Total �engfk------- (.Q-g--------------------------- <br /> Seepage Pit: Distance to nearest well----- ---------------Distance from foun'dation foundation----__-------------Distance to nearest )ot line_-._--_-----_.-L <br /> Ll Number of pits- ------------------ ---------- <br /> Lining material------- - ------------Size: Diameter------------------------Depth--------------------------------- <br /> Cesspool: ;""Distance from nearest well-------" ------Distance from foundation--------------------Lining material-------------------------------- <br /> El. Size. Diameter.---1------------------ ­..........Depth - <br /> --- ------------------------- ------- ------------ Uquid Capacity---------------------------gal <br /> Privy: Distance from nearest well----------------------------------------- <br /> --------Distance from nearest building--------------------------------- --- <br /> 0 Distance to nearest lot line.-.._ <br /> - ------- <br /> Remodeling and/or repairing (describe':---------- ---------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------I <br /> -------------------------------------------------------------------------------------------------------- ----------------------- ---------------------- <br /> ------------T i <br /> ---------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------- ----------- --------------------------I ----------------------------------- <br /> I -------------------------------------------------------------------------------------------------------------------------------------- ------- <br /> 7 <br /> - ---- - -- ----- <br /> here6y 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 an&regulations of the San Joaquin Local Health District. <br /> --------- -------- r Contractor) <br /> ', cf or) <br /> By:.---------------------------------------------I /- ------------------ ---------------------------- --------(Owner an Contractor) <br /> i ------ ---------------- -----------------------------------------------Title-------------- ------------- ----------- ----- ------ --------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> I FOR DEPARTMENT SE ONLY <br /> APPLICATION ACCEPTED BY----- <br /> 7 --t'_ . ..... - -------------- - <br /> ------------------------------------------ DATE--------07-7!�Z�7� <br /> V Y <br /> REVIEWED BY - ----------- ----------------- <br /> T ------- ------ ------------- - - ----- ------ --------------- ------------------------------------------ DATE <br /> :-------- --------------------- <br /> �s�6 6 ................... <br /> BUILDING PERMIT ISS--��E6- -----------------------------------------------------------—-------------------------------------- DATE <br /> Alterations and/or recommendations <br /> ------------------------------------------------------------------------- -------------------------- ----------------------------------------------------------------------------------------------------------------------- <br /> ....I------------------------------------------------I---------------------------------------------------------------------------------------------------------------------------------------------------------------­ <br /> ------------------------------------------------------------------------------------ ------------------- -----:-----------------------------------I----------------------------------------- ------------ ---- ---- -------- <br /> ----- ------------ ------------------ ----------------------------•------ -- ------------ ----------------------------- --------------- - -------------------------- ------------------------------------ ---------- <br /> FINAL INSPECTION BY:- ...... ` <br /> ­, ­)-- <br /> 13—a----- ------------- ----------------------- ---------- <br /> 4 Date--- - ------ <br /> - <br /> ------------ <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 <br /> Tracy,California <br />