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FOR OFFICE USE <br /> ----- APPLICATION FOR SANITATION Ir,,(MIT Permit No. <br /> --------------"------------------------- ----- - ........ (Complete in Duplicate) pate 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 County Ordinance No. 549. �- (� <br /> ` JOB ADDRESS AND LOCAT ON____� % J _------- -- <br /> . <br /> �. <br />? Owner's Name f�----- --------- -----6----7 Phone <br /> Address / ;' '= <br /> Contractor's Name------------------------------------ <br /> '-1'` -- ------ ------- ------------------------ Phone---------------------- <br /> Installation will serve: Residence ❑ Apartmen House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Of 7� i <br /> Number of living units:_ Number of bedrooms _-Number of baths -___I__ Lot size C.111t_ <br /> ----------------------- . <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 ❑ andy Loam ElClay Loam [I Clay ❑ AdobebKHardpan ❑ <br /> Previous Application Made: (If yes,date_______________,_.._) Nox, <br /> New Construction: YesA No ❑ FHA/VA: Yes ❑ NOV <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> __(No-septic tank or cesspool permitted if public.se er.is.available within 200 feet.) <br /> Se i Tank: Distance from nearest well ---Distancefrom founda�ion-- Mater al fJ - <br /> Size- U 4�- <br /> No. of compartments-----� - ff - ------�-�-------h-...�?_.Liquid depth----------- � ----- Capacity_ <br /> � -�-�----" "7 <br /> Disposal Field: Distance from nearest well- I__�'J-C1---Distance fro fu�dation---- _l ----------Distance to nearest lot li e <br /> Pr Number of lines �� .......... r f.l__._ : <br /> en th of ea h ne.-._ - +�Q_.Width of trench_ _.-�_ t <br /> a � _ <br /> g �- <br /> T e of filter material-�S" e th of filter material_____ Tota! len th___._ d <br /> Yp p 9 <br /> Seepage Pit: Distance to nearest well-----_----------------Distance from foundation--------------------Distance to nearest lot line_.____.._______._ '7 <br /> ❑ Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------Depth----..___------------------------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------------.-------Lining material------------------ _--_______.___. <br /> ❑ Size: Diameter--------- - ------- -----Depth--------------------- --------•------------ ------Liquid Capacity- --------------------------gals. <br /> •. - ; <br /> Privy: .. h• Distance from nearest well-_-____.__�___"._.__�_"....________"___ Distance from nearest building.___"____ ------------------------ � <br /> ❑ Distance to nearest lot line <br /> Remodeling and/or repairing (describe) ---------------------------- ----- --------------------------- --- - -----------------------•------------•------------------- <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, and rules and regulations of the San Joaquin Local Health Dis+rict. <br /> �Signed) Ir. 9 }-----��,- ---L -- —-------- ------- -------------------- -- -- ---------------(Owner and/or Contractor) <br />---- . <br /> --------------------------------------­_- `-------------------------------------------------------- ------------------------(rile)-----:-- <br /> (Plot plan;,showing size of lot, location of system in relation to wells, buildings, etc., can be placed°on reverse side). <br /> 4' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ---------------------------------------------------------------------------/- -- - ------ ATE___' 1 ; <br /> REVIEWED BY--------------------------------------- ------ ------------------------- ----------------------------- -- - <br /> - • - -. DATE-- •- ---=�-��-----' : - ------------------- � <br /> BUILDING PERMIT ISSUED-------------------------------------------------------------------------- --- '------ f ------- DATE---- ----- -------- ------- <br /> ------------------------ <br /> Alterations and/or.recommendat ions:----- -,----- t <br /> i <br /> --------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------•------------------------- <br /> ---------------------------------------- <br /> ------------------"------------------------ ----------•-------- --------------------------------------------------------------------------------------------- .... -------------------------- <br /> --------------- ---------------- .......... <br /> =----------------- ----- ---------- ------ ----------------------------------------------------------------------- ---------- ------------------ ----------------------- } <br /> f <br /> FINAL INSPECTION BY----------------- ---- - --------------------------------- ---- Date-- ------ <br /> - /--- <br /> --------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F.P.C o. ...,.. y <br /> 4 # <br />