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FOR OFFICE USE: <br /> ' _-.---- APPLICATION FOR SANITATION PERMIT Permit No. 1. 1 " <br /> --------------------------- -- --- ----- --------------- <br /> - (Complete in Duplicate) <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued 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 ATION---- f '� -- 1 :. = ' ---------''/------- <br /> / / Phone------------------------- <br /> Owner's Name--------------/-- --�-/�---�-•-`-�--•-•--------��--�'----�---...�..� ------- - - - ------•--- <br /> r <br /> Address--------------- ' -- ' -- •- ��-- :'�' 1 <br /> s ,��f ti <br /> Contractor's Name------ -- ----�- ... /` v j -1/Y -----------. Phone..,,---------- - <br /> Xb <br /> Installation will serve: Residence Apartment House,.❑ Commercial ❑ Trailer Court ❑ Motel ® Other ❑ <br /> Number of living units: _____'Number of bedrooms ---I"Number of baths ___-Lot size ----AQQ--- / _ ________________ <br /> Water Supply: Public system [A,-/Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a 'depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam EJC lay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: [If yes,date--------------------) No New Construction: Yes ❑ No D11_11PHA/VA: Yes ❑ No ❑1" <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspoolrpermitted,if-public sewer is available within 200 feet.)- �{ <br /> I <br /> Septic Tank: Distance from nearest well_________________Distance from foundation--------------- -Material--- <br /> E] No. of com 4rtments----------•--------------Size------------- ------------------Liquid depth------------------------- Capacity----------------------- \ <br /> , <br /> Disposal field: Distance from nearest well------_.v..._.Distance�from fouridat.ion___ ------.------_Distance to nearest lot line_z�._J._.. <br /> Number of Imes------___ ---Length of each line _ ..Width of trench___._ ' -- ______._ <br /> Type of 'filter material_ P�/_ ___Depth of filter mater+aL._Y----------- otal lengiil"i�l •_ __�_ y�G---__.__.__ O <br /> Seepage it: Distance to earest,well-=___--_-_-c-__Distance fn-foundation__�,_ =__.Distance to nearest lot line____��.� � <br /> Number of pits-------- -----------Lan+ng material__f-5X y/e---.Size: .-------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--_______.___.----Lining material------------------------------------- <br /> ❑ Size: Diameter <br /> V # <br /> rt peter------------------- -- - ----------Depth------------------------T---------------------------- <br /> Liquid Capacity-- ------------------------gals. <br /> i - - <br /> Privy: Distango„j!om nearest well._- -- -- _ -------------------__Distar e from nearest building.___ --------- <br /> ❑ Distance to nearest lot line • I r ----------------------- -t � I <br /> -------- <br /> Remodelingand/or re a+nn descr+be :___._ ._ ��T�______��,2'�.:�I�`���-�-.___-- ___��.19//l/-------------------- <br /> � p 9 ( ) -- - - <br /> ----------------------------------------•------------------------------------------------------•---------------------------------------- <br /> - <br /> -I hereby certify that I have, repared this application and that the work will be done in accordance withSan Joaquin County <br /> ordinances, State laws; and rul "and regu tions of the San Joaq i7n , <br /> 0-Health District. <br /> t--� : <br /> :_- iC�. �.,/ /{/�$---------C ! --,------- Own P and/or Contractors <br /> [Signed) - - --- ----- <br /> By: <br /> --- w _ =• / r <br /> By•---------- ��� -- -----------------------{Title) - -/- --------------------------------------- <br /> --------- ---- <br /> (Plot plan, showing size of lot,Ibca Eon of system n relation to-wells-15 <br /> o.-wells-1 5 (dings, etc., can be placed on reverse side). <br /> *44F- '' <br /> 1; FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY r .. - ------------------------------------ DATE.--- �' G }�---- ------ <br /> REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE-------- ------ ------------- --•-------------- ------------ <br /> BUILDING PERMIT ISSUEQ - ------------------------------ '. ""-------- - -- DATE._ -: _ <br /> Alterations and/or recommendations:._ T--.{ ---------------- <br /> ------------------------- <br /> -------` <br /> -------------------------i------------------------- ---- ------ <br /> --------------- -------- <br /> y / <br /> -- ---; ....--- j - -- `--- r <br /> t 11 1L e <br /> ------------------------ --------- --------------- ---------------- - --- ------------------- -------- ------­-------------- ------ 1 <br /> FINAL INSPECTION BY: /�/ ........... <br /> --- ----- .. <br /> ....... <br /> -- Date- '� Y�'--5 -- <br /> + SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hoielton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F.P.CC. <br /> 1 <br />