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FOR OFFICE USE: <br /> ---- ------------------- --- ------------- .......... <br /> .- APPLICATION FOR SANITATION PERMIT Permit No. <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 construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS LOCATION.. . -. 21 ' lam'- --------- ------------ <br /> : -- --- Phone Owner's Name-- --mss--d------- -- - ------ -- -- --- ---- --- ------- `" <br /> Address 5� �Y ------a-----------i------_-- ---------- ; <br /> Contractor's Name.----- f�1 xs-cam �'�y''`--`-_- " ------ - ---- • - Phone------ <br /> ------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel. ❑ Other ❑ <br /> Number of living units: .-f... Number of bedrooms ..4_ Number of baths.__/---- 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: llf yes,date--.---.-.---------- ) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic°tank or cesspool permitted if public sewer is available within 240 feet.) <br /> Septic Tank: Distance from nearest well .._.. ---------Distance from foundation------------------- Material ---------------------------------------------- <br /> No. <br /> ---._-------------------------- ------------No. of compartments--------------' --Size-------------------- -------,---Liquid depth--------- --- --- ....... Capacity----------------------- <br /> Disposaj,-Field: Distance from nearest well.... -_`-..Distance from foundation--.!d ..Distance to nearest lot line-..X---------- <br /> ET Number <br /> -_----- <br /> Number of lines --------L------------------------Len gthy-of'each line....-/ --../----------.Width of trench--. - <br /> i ,,,-Type of filter material--- •S.c��_-_-__.Depth of`filter material ------------Total length:...--/!e '-------------------------- <br /> See pa Pit: Distance to-.nearest well..._./Od_"-...Distance from foundation------�E?--�._-.Distance to nearest lot line-.�.__.--_.- <br /> Number of pits.-- .../.........---Lining materia'I�^� -'-- Size: iam <br /> Deter------ �•-....Depth---- ---5------------------ <br /> Cesspool: Distance from nearest well ................Distance from foundation................. ..Lining material_-Y-_._----.-.----------------.---- <br /> ❑ Size: Diameter. ------ ------ --------- -----Depth----=-- -----;--- ------ ,- ------- ----- Liquid Capacity--'-------------------------gals. <br /> Privy: Distance from nearest well. ----------------------- - -Distance from nearest building_.__::`_..--.------------..-..-_----. <br /> ❑ Distance to nearest lot line---- --- ------------------ ------------------------- - `-------------------------- <br /> = - _: <br /> j} -. f, <br /> Remodeling and/or re airin <br /> ( escri�e):--9 -- -.------ ---------------- ------------------- <br /> _ ------------------------------------------------- <br /> ------------ <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, and ule and regulations of the San Joaquin-Local Health District. - <br /> (Signed)----------- ------------- - -- -------------------•----------------------------- {hand/or Contractor) 1 <br /> !? == ----- 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 /> I <br /> APPLICATION ACCEPTED BY--.- ----------------------------------------- DATE--{ 7-P� ------ -----------•------ <br /> w REVIEWED BY------------------- ------ ----- ----------. ---------------------------------- --------------------------------- ------ DATE-------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-------- ---- ----------------- -------------------------------------------------- ---------- DATE--------------------------------•---------------------------- <br /> Alterationsand/or recommendations:-------------------- - - -----------------•-----------------------------------•---•---- --------------------- ------------------------------ <br /> -------------------- --------------- -- --------------------------------- ----------------------------- ------ --------------------------------------•-- ------------------ ------------------------------------------ <br /> 1. <br /> ---------------­--------------- ------------------------- ----------- - ----------------------------------------- ------------------------------------------------•-- ------------------------------------------ <br /> -- •---=-- ---------------------------------• ----------------- --------------------------------------------------------- -----------r------ -- - -------- --- ------ - - ---------- ---- <br /> i FINAL INSPECTION BY:. Date-...1.�.�. �.(� L <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 20.5 West 9th Street <br /> Stockton,California Lodi, California Manteca,California Tracy,California <br /> 't� E.H.9 2M 1-67 Vanguard Press <br />