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FOR OFFICE USE:-------------- <br /> ' <br /> ,< <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> -------- - -------------------------- (Complete in Du <br /> ------------------ plicate) /moi f <br /> " <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 /> JOS ADDRESS AND LOCATION..•--C;V- -------------------I——------------------------- <br /> Owner's <br /> -•—------------------------- <br /> Owner's Name------------- - / --- ------------------------ Phone--- .7� --�.. <br /> Address---------------- >1-------- 1' ----- <br /> Contractor's Name-.-.- <br /> ---------------- Phone_Installation will serve: Residence ❑ Apartment House ❑ Commercial a Trailer Court ❑ Motel ❑ Other ❑ <br />'I Number of living units: --- - Number of bedrooms --0-_ Number of baths /___ Lot size ____._"_____________________________________________________ + <br /> Water Supply: Public system N Community-system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam DQ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (if yes,date--------- ;}' No §4- New Construction: Yes 21 No ❑ FHA/VA: Yes ❑ NON <br /> J <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'_"__ "__,µ_Distance from foundation__. ___.____.Material----- ek_-_--.-_ r----_____. <br /> No. of com artments_____-_._' __ "� `� <br /> p Size , Liquid depth _------- Capacity <br /> Disposal Field: Distance from nearest well.-._--i---------Distance from foundation--_4�.�--___-Distance to nearest lot line___-a�a__�_ <br /> , <br /> Number of lines_"_"_-'___�-�.- ___-----------_Length of each line_______�r�' ___f�__-_-.Widfih of trench"_�_yl.___________________ <br /> Type of filter material___:_ � j�!__Depth of filter <br /> . material_--"%0-__-r---__Total length___________________.._____________._�_ <br /> _._ <br /> Seepage Pit: Distance to nearest well------" .........Distance fro foundationpto nearest <br /> lot .______ <br /> JX Number of pits........_/_$.......Lining material____ � -----Depth---- .5_ - --------------- <br /> -r-Size: Diameter <br /> I Cesspool: D•stance from nearest;well-___.__ -----..__Distance from foundation---_-----_---------Lining material___-.-"_____________________________. r <br /> ❑ Size:Diameter.----- ---- A' ------ ----.-Depth----------------------------------------------------Liquid Capacity----------------- --- ----gals. %Od <br /> Priv Distance from nearest:well________________________________-_._._._ <br /> Privy: - Distance from nearest building______________________________�._i_."_____. <br /> - <br /> ❑ Distance to nearest lot'line---------------------------- - --------------------------------------------------------------- ----------- <br /> Remodeling and/or repairing (describe):-------f/ GC?---------- .�;_:51_T116-1f-f----------------------- <br /> f. <br /> I hereby certify that I have prepared this application and that the work will-be`done in accordance with San Joaquin County <br /> ordinances s, and rules and regulations of the San Joaquin. Local Health District. <br /> (Signed)------ -------- f--- -". --------------------- ----- ----- ----------------------- - wn and/or Contractor) <br /> B •------------------- --------------� -�•---------------------------------------------------------------- Title - :_ <br /> Y• ) - ---e------ ---- - <br /> (Plot plan, showing size of lot, loc on of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------ ---------- ------- - ------- DATE-'_--m <br /> } <br /> REVIEWEDBY------------------------------------ ---- ---------------------------------------------------------------------------------- DATE -------- ---------------------------­- <br /> ------PERMIT ISSUED ------ ---------------------------- DA•TE----------------------------------"------------------------ <br /> ' Alterations and/or recommendations:____ /!- ___-_ =_._.-� _"- � _____-____________ _ _ <br /> ----------- --- ------------------ <br /> / l - ----------=--- ---------•--------------------------- <br /> E� <br /> "c f ------------ -------- ---------- -------- - ---- --------- ------- <br /> � `fes' --------------- - � f <br /> -- -—. ----------- --------------------- --------------------------- -------------------------------------------------------------- <br /> I <br /> .......... ------------- ----------------------------------- --------------------------------------------------------------- - -•---------- --------- ------------------------------------------------------ <br /> FINAL INSPECTION BY:. ] Date-- ----- / _;.y4__.5------------------------------------ <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F.P.=, I <br /> f J <br />