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APPLICATION FOR SANITATION PERMIT Permit No. <br />(Complete in Duplicate) Date Issued ---------- ; ----------- <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work here:%scx1bed. <br />This application is made� in-compliance'with County Ordinance No. 549., S�lc 1� <br />JOB -ADDRESS AND i LOCA l 0 <br />N__ __j -- ---- ----- ---- --------- - ------- <br />----------- ------------------ <br />Owner's Name' ------------ i ----- <br />-- ---- & -------------------- Phone ------------------------------------ <br />---------------------------------- <br />.... ... . .... . . . ..... <br />Address.._ ---------- - -­ 5.1 --- 7 ------_----- ------- -- ----- --------- ----------- ­ <br />---------------------------- ------------------------------- -------------------------------------------- - <br />Contractor's Name.- -I ---- ��v ----------hone <br />- <br />Installation will serve: Residence 0Apartment House El Commercial ❑ Trailer Court E] Motel ❑ Other E] <br />0 - rgll <br />Nurhber of living units: N'tutr'n'b'er of bedroomsf Number of baths Lot size x . .......g_.....e- ---------------------- <br />Water Supply: Public system'E]' 'Co.nmdnify system E] Depth to Wafer Table ff. <br />Character of soil to a _depth '�0'0­feet: I Sand ❑ Gravel E] Sandy Loam 0Clay Loam E] C1 . ay n ,Adobe ❑ Hardpan E] <br />Y <br />Previous Application' Made: Yes El No UKINew Construction: Yes 0'-N,*-.Ej_ FHA�/NiA:_''D No El <br />M. <br />TYPE -'OF INSTALL-ATION,AND"SPCel'FICAT16NST -- <br />r. <br />(No seBac. <br />,,Wnk or'cesspool pe'rAiif�e_d ef'public 'sewer is available witkin'200 feet <br />7 <br />A15k Distance from nearest well --- ------ Distance from found - ----------------- lvla'f� ----------------------- Ql) <br />Septic ption <br />N .......... *4 - — --------- Sie__10.X__�__A_b ------ Liquicl,depf h: ---.--g -_______________'_Capacity_ _,Z4? <br />f.compartmen-I _e) <br />7? i� <br />D' t t rest lot I' e-li, ------- <br />Dispisal Field: Distance from nearest n - --------- is &nce o nearest 4o�:Sl <br />SIL_ Distance from fou'nda. io 0 -5 <br />I / , 10 ldth' of french- <br />N6mber of.lines ------ -- 6 - Length of each hnel.," A trench_.________________________ <br />................... <br />L .... <br />'+�l length ---- Z_ 0-4.---------------------- <br />See <br />0 <br />Type of filter.. --- "G- __Depth of filter materiall ---- - ------ To ----- : ---------------------- <br />Seepage pit: Disf8nc� to ne'aresf well "__---____'_________Distance -'_--'_fro M- foundation_____ 7=nce't�'-n6_a`rest_ Gf'.Iine ----------------- A <br />F-1 FNumber of pits ----------------------- Lining r material- -r -------------- ...... Siz'q! Diameter ------------------------ Depth --------------------------------- <br />F <br />Cessp6ol:, Distance from nearest well______________ Distance'on .. <br />from foundati............. ---- �:Linin.g material_:__________________________________ + <br />Size: Diameter ------- -- -------:_'_De pt h ---------- . _L <br />--- - ----------- ------------------- Liq'uid_Capacif ---------------------------- gals. <br />Privy` Distance from-neares't well_____________________________-_- _ _______,----Distance from nearest building__-_-______________---- 7 ---------- <br />F-1 Distance to nearest lot kne ------- ----------------- ---------- --------------------------- I ---------------------------------------- <br />t <br />Remodeling and/or repairing (describe): ----------- <br />- <br />pa --------------------------------------------------- <br />-------- -------------------------------------•--------------------­- ------------------ 0 <br />-------------------------------- ---- ----- ------- --­---------- ----------- ------_-------------------------------------- ------- ------------------------------------------------------------------- <br />-------------------------------- 4 . I ---------- --------- I --------------------- : ---------------- - F <br />- --------------- ....... --------------------------- -------------- 1-1 -------- -------------------------------------- <br />-- --------------- � i . . . . .. f7 t. * . , : <br />---------- -------------------------------------------------------------------- ------------------------------------ ---------------------------------------------------------- --------------------------- <br />Fhereby certify that I have prepared this application and that the 'work will be done in accordance with San Joaquin Count <br />ordinances, State laws, and rules and regulations -of the San Joaquin Local Health District. <br />(Signed] ---- -1-01--------{Owner 'and/or -Contractor)_---tBy:----------------------------------------------------------------------- -------- ------ -----------------------------(Title)-------------------------------------------------------------- <br />(Plot plan, showing: size of I.ofjocation"of system in.relation to wells, buildings,- etc., can be - placed on reverse side). <br />FOA DEPARTME19,TIUSEONLY <br />APPLICATION ACCEPTED <br />REVIEWED BY-------------------------=------------ <br />---------------------------------------------------------- <br />BUILDING PERMIT ISSUED.---- ------{-----------------------------`---------•-------------- <br />Alterations and/or recommend afions: ----------------------------------------------- --------- <br />--------------------------------------------------------------------------------------------- - <br />----------------------- <br />-------------------------------- DAI L -------------- ---------------- <br />---------------------------- DATE---------------------------------------.. <br />-------------------------------------- ------------------- <br />___________________________________________________ <br />-------------------------------------------------------------------------------------------•---- <br />________________________________________ <br />------ <br />6 <br />.. ir_ 1 <br />4 . - <br />I ---------------------------- <br />---------- --------------------- <br />­­ <br />----------------------- ------------------------------- <br />FINAL INSPECTION -BY: <br />t --------------------------------------------------- <br />- <br />-------------- ------------------------------------------------------ <br />i ---------------------------------------- <br />--------- <br />--- -------- <br />_r -------- ---- ------------------------------ <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />130 South American Street <br />300 West Oak Street <br />132 Sycamore Street <br />814 North "C" Street <br />Stockton, California <br />Lodi, California <br />Manteca, California <br />Tracy, California <br />ES -9-2M . Revised 1,57 fRCO. <br />