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y FOR OFFICE USE. <br /> ' z <br /> 7�'z' I't°ct <br /> --- 4 <br /> APPLICATION FOR SANITATION PERMIT 1 Permit No. <br /> � <br /> . <br /> � ------------------------- / <br /> ----- - --------------------------------------------- (Complete in Duplicate) <br /> -------------------------------------- <br /> __--___-____._.__. )This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San l oaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinanc 549. " <br /> / <br /> JOB ADDRESS CATI N- ` <br /> f 4 �� .- . <br /> lPhone........................ <br /> ---- --------- <br /> Owner's Name = ....Address------------ ------------ ................................................;-----------------•---------.. <br /> Contractor's Name <br /> -----------=--------------------------------•-•-- -••---..'. Phone.. <br /> Installation will serve: Residence Apartment House'[] Commercial ❑ Trailer Court ❑: Motel'❑ Other ❑ <br /> Number of living units: _.-t___ Number of bedrooms __Number of baths ___t____ Lot size ------------------------ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -. ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam-❑ Clay ❑ Adobe[Hardpan ❑ <br /> Previous Application Made: {If yes,date_(Q-+�1_r_�f---) No ❑ 'New Construction: Yes E] No FHA/VA: Yes ❑ Noe <br /> TYPE OF INSTALLATION AND SPECIFICA�& _ ._. _ <br /> (No septic tank or cesspool permi#ed if'public sewer s available wifhin 200 <br /> Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material----------------------------------------------- <br /> .. <br /> ❑ No. of compartments--------------------------Size....... = 'Liquid depth-------------------------Capacity.....- -------- ! <br /> TO Distance to nearest lot lme_____-\..__..... <br /> spos Field: Distance from neares well----- -------Distance from. foundati 1 <br /> Number of lines_______, _-1-�_ _Length of each line_`"` _ Width of trench,�___Z - i <br /> f� ss -- --��•----- � --------------- <br /> Type of filter mat- __ ____ ___0c _ -.Depth of filter material-------I.�_ ------Total length--------9..---_-•--•--•--•-•---------- \ <br /> Seepage Pit: Distance to nearesfi well_____________________Distance from foundation_______-__-•_'____.Distance to nearest lot iine._.._______...... <br /> ❑ Number of pits---------------------Lining material--------------.--------Size: Diameter-----------------------Depth---------------- <br /> Cesspool: Distance from nearest well--- -------------Distance from foundation--1_---------------Lining material-_____-- ___.____._-_-____________- ( t I <br /> X11 i <br /> ❑ Size. Diameter--------------------------------- _' <br /> - ''Depth_'--'--"-------------------------------------------Liquid Capacity----------------------------gals, <br /> Privy:. Distance from nearest well---------- -------------Distance from nearest building_____---__._-__________________-_-.______- <br /> Cl Distance to nearest lot'lin ----------------------------------------------------------------------- <br /> •---•--------------------------------------------------------- <br /> - � <br /> t <br /> ------ _- •- -----= . -- - <br /> -- --- - ----- --- -- - ------------------------------------------ -------------------- <br /> - ---- ---- - <br /> F <br /> ---------------- ---------------------------------------•- •--------------- <br /> y. a ------------------------------------------------ ------------- <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, St to laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) ------------------------------------------r-`--- ----------------------------------(Owner and/or Contractor) <br /> ;�Ji <br /> By: ----------- - <br /> --------------------•--------------------------------------------------------------------------------- ----- <br /> .-• !".(Title)---------- ---------------------'------- -- -------------------- <br /> (Plot plan, showing size of lot, location of system in )elation to wells, buildings, etc., can be.placed on reverse side). <br /> FOR DEPARTMENT USE ONLY] <br /> APPLICATIONACCEPTED BY------------------------- ---------------------------------------- DATE..------------------------ ----------------------------- <br /> REVIEWEDBY--------------------•--•---------------------------- -- ------- ------`-------------------------------------------•- DATE--------------------...--------._ ---•-------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------•---------------------------------• DATE------------------------------------------------------------- <br /> Alte'r tonsnd/or recommendations:-------= --- - --------------=--•-•-•-- ---=---' ------------------------------------------------------- <br /> Md - / ------------------------­- --------------------------------------------- <br /> ---------- 1---------------------------------------------------------------------•----------S-----------------------------------------------------------------I -- ------------ <br /> ----------- <br /> FINAL INSPECTION BY:-/,?,4 r., <br /> � cy Date ------------------------------ <br /> --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> Ee•9 REV19E0 19-69 F.P.Ca.ZM 6-60 % <br />