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FOR OFFICE USE: <br /> q., <br /> ........................................ APPLICATION FOR SANITATION PERMIT Permit No. I/...��� .-.. <br /> -- <br /> (Complete in Duplicate) <br /> -- - - - Date issued <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 C my Ordinance No, 549 <br /> JOB ADDRESS AND L CATIONr 16; <br /> ----------------------------- -`-----------•--------------------------------- <br /> �-U1 ,a. <br /> Owner's Name--------- - •-- ----- --- - -- - - - - � --------------------= ------------=---._ pi,hone <br /> Address----------•-------•--- � �3r <br /> Contractor's Name------ --------- -- -- - -- ------- --------------------------------"---------------------------------------------------- Phone-44--i <br /> Installation will serve: Residence Apartment House ❑ Commercial Q Trailer Court ❑ Motel"❑ Other ❑ <br /> ~ <br /> Number of living units: ___[__ Number of bedrooms - ___ Number of baths _- Lot size ___ ____19 .__ __-__________________________ <br /> wi <br /> 1N ater^,:Supply: Public system El Community system E] Private Depth to Water Table ft. <br /> Gha�acter of soil to a depth of 3 feet: Sand ❑ Gravel Sandy Loam ❑ Clay Loam (] Clay ❑ Adobe❑ -Hardpan ❑ <br /> Previous Application Made: iff yes,date-_--_,.--- ) No New Construction: Yes ❑ .No ❑ FHAt/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public s�wer is available within.200 feet.) <br /> Septic Tank: Distance from nearest ----Distanf es rom f ndatiP -----------------.-Material -fT---- <br /> fes <br /> __._:______________________ <br /> No. of compartments _______r._Size � b___ .�fJiquidpth____....NL ------Capacity---1.44a.- <br /> Disposal Field: Distance from nearest w ll- � Distance from foundatpn_ _____F.__. ys#ante to nearest Io linesr _.. <br /> �% --------- <br /> Number of lines-------------— Lengtf, of each line/4_'(,e �_- idth of trench._.-_ y <br /> Type of filter mate ria Lf_,2 Depth of filter material-----�------------Total length___. )_4_______________------------_ <br /> Seepage Pit: Distance to nearest well-------------__-------Distance from foundation---------------------Distance to nearest lot line--._--________--_ <br /> ❑ Number of pits------------:-------Lining material-----------------------Size: Diameter.----------------- ----Depth---.----------------------------- <br /> . <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material_-_.-_._.---_____--_.__---____------ <br /> _._Y -, <br /> v -- ---- ------Liquid Capacity----------------------------gals. <br /> Priv❑ Distance Irom nearest-weTl------•----------- --------------------.---__---- isan`ce"Tr~m <br /> Size: Diameter------------------------- - ----------De th----------------------------- _ <br /> om nearest bui(ding.. -------------------- ----- <br /> ❑ 1Distance to nearest lot line------------- <br /> ___-_---___ - <br /> ----- ==------------------------------------ --------------------- <br /> Remodeling and/or repairing (descrii,e}: _ <br /> ---------------- ----- r <br /> ------- ----T <br /> --- - ----- ' <br /> ---------------------------------------­­------------------- -------------------------- ----------------- --------------------------------------------------- ----------------------------- -- <br /> ----------- ----------------------- -----------------------------------------------------------------------------------------------------------•-------------------------- ------------ � <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, State laws, a d rules and reguiation he SanJoaquinLocal Health District. <br /> (Signed) .- AAi -------------- ----------------------- --------------------------- ---- -------(Owner and/or Contractor) <br /> Ry:-------------------------------------------------------------------------------------------------------------------------- --------(Title)------- -------- ----------- <br /> (Plot plan, showing size of lot, location of system in relation to wells,.buildings,-etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------- ---------- <br /> -------------------------------------- ------------------------- - ATE <br /> REVIEWED B <br /> ------- ------- - ---- _v._. DATE-- - } .------------ <br /> BUILDINGPERMIT ISSUED------------------------------------------------- ----------------------------- -.;---------- DATE---- --------------------------- <br /> Alterations and/or recommendations--------------------=---------------------- I--------------< ------------------------• { <br /> i <br /> -------------------------------------------------------------------------------•-------------------------------------------------------,----------•--------------------- ----------------------------- ---•-•------------ <br /> ---------- ------------------- --•--------------------------------•-------- ----------------- ---------------------------- •----------------------- <br /> - ------------ ----- - ------ ------ ----- - - - --------------- , ----- ------- ------ <br /> FINAL INSPECTION; BY-- - Date---- -- 0.'Yl. .�'lo ------------------- p <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,Colifornia Tracy,California <br /> F.F.0 C. <br /> R <br />