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FOR OFFICE USE: <br /> i <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> -- <br /> ------------------- ------------ --------- <br /> --------------------------------------------------------- t <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 con tract and install the work herein described, <br /> This application is made in compliance with County Ordinance No. 549. 6_53-- 2_Y-0 2 <br /> r <br /> JOB ADDRESS AND LOCATION------------------------.----- -- ------•-._-- -1 <br /> Owner's.Name----- r�� = -u- P.� -•---••-----•----------------- ---------.... Phone------------------------------------ <br /> ---- <br /> =- - ---------------------------------------------------•------------------------ <br /> Contractor s Name____________� <br /> Phone <br /> Z�--- <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units, INumber of bedrooms a.7_. Number of Baths __/___ Lot size ______ _---_----------------------- <br /> ____--_-___..__:_.__ <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Tabler?Q_ 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.--- ---------------] No P---New Construction: Yes ❑ No [P_- 1 NA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> - <br /> (No septic fan or-cesipool-permitted-if*public-sewer-is=evailable-within200-feet:j <br /> ep j6 Tank: Distance .from nearest well_________________Distance from foundation-_----------------.Material________,____-___.___._.____.___..__________- <br /> "" No. of com artments_____..__________________Size___-____------____._________.___Li Liquid de 'th__._________._....______iCa acit <br /> p 8 f �- q P i p Y 41 <br /> Disposal Field: Distance from nearest well-�.._ -_Distance from foundation__f4�__r_.__.Distance to nearest lot lines___ , <br /> [� Number of lines________ ________ _ _______Length of each hne---l_d-6_.............Width of trench.___��__.Y_ .. C <br /> Type of filter materiaLs4____ _�C_h_.__Depth of filter materia!___._,l _� ------Total length__ ----------------X_4_0--_.____- <br /> t <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 /> Cesspool: Distance from nearest well-------- Distance from foundation____________________Lining material------------------------------ �1 <br /> ❑ Size: Diameter------------------------------------.Depth_-------------------- ------------------------ ---Liquid Capacity----------------------------gals. C <br /> _.Distance from nearest building Privy: Distance from nIearest well------------- -- ---- --------------- g----------------------------- ---- ---- - V+ <br /> ❑ Distance ;to nearest lot line________________________ <br /> t <br /> Remodeling and/or repairing (describe),;.___.._._.___f_______ ________ ____ <br /> w ' <br /> ,� . . L,� I i ? <br /> t I I <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 District. <br /> (Signed} ----------- . -- ----- <br /> (Owner and/or Contractor <br /> By: ------------------= 7 :------­------•-RLL.__------ --------- ----------------------- ` -------- �{Title} ���----r.�..�_ <br /> (Plot plan, showing size of lot, location of sys+em in 4lation to wells, buildings, etc.,~can be place on reverse side). <br /> l } <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY___ 1.4� _ DATE__ _ '�5�___.__________________________ <br /> - --------------- -- ------ <br /> REVIEWED BY------------------------------------------- --------------------- ----- ----- ------------------------------------------ DATE------------------------ <br /> - --- - --- <br /> BUILDINGPERMIT ISSUED------------------- ------------------------------------------------------ - - ----------------- DATE----------------------------------- ----------------------- <br /> Alterations <br /> ---'---- <br /> Alterationsand/or recommendations:----------------------------------- --------- -----------•-----------------------------------•- ------------------------------------------------------------ <br /> -----------------------•---•---------------- ------------------------- --------------------- ----------------------------- ------------------------------------------------------`-------=---------------------------= <br /> ----------I------- ------------------------------------------------------- ------------------­­----------------------------------------------------------------------------------- ----------------------------------- <br /> ----- --------------------------------------- ---------------------------- ----- - --------------------------------------- .,----------------------------------...------------------------------------------------------- <br /> FINAL INSPECTION BY: ' 4", " Date--- ��C�.� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1801 E.Hasellon Ave. * ,300 West Oak Street *` 124 Sycamore Street 205 West 9th Street <br /> Stocklon,California Lodi,California �' Manteca,California + Tracy,California <br /> F.P.CO. <br /> f <br />