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FOR OFFICE USE: <br /> ---------------------------- ---- --------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. 1.yT __ <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 Co my Ordinance No. 549. C <br /> 1 JOB ADDRESS LOC ` /lG � .f <br /> Owner's Name <br /> ,t <br /> Phone__.. - <br /> om_-rel--------------------------------------------- <br /> Address__________ <br /> Contractor's Name----------4------ - ---------------------------•-•--•----•----- Phone----•----------------------•------- <br /> Ittstallation will serve: Residence 'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: - -- Number of bedrooms ,.,?-- Number of baths _`_- Lot size -Alf-D_s_--.Avg-F----------------------------- <br /> Water Supply: Public system E] Community system ElPrivate 2!r"_Depth to Water Table PA ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2-'O'Hardpan ❑ <br /> Previous Application Made: (If 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 200 feet.) <br /> Septic Ja k:i Distance from nearest well-----------------Distance from foundation----------•--------Materia4------------------------.--------------___.-.--_. <br /> No. of compartments-- --------- ----- ----Size------------------- ------------Liquid depth---------------- ------- Capacity...--- ----••-----•---- <br /> Disposal Field: Distance from nearest w0_444?_ Distance from foundation _l4?_.________.Distance to nearest lot line%0--____---- <br /> �, Number of lines-------- .......... <br /> ....- .__//_Length of each line_____'i -------- <br /> -`---�r----.Width of trench-__ ._____---_-.-----._.- <br /> ,� r Type of filter material-1 �CCeDepth of filter materiaL____��_--_._..Total length-__- �-------------------------__- <br /> S�page P'#: Distance to nearest well__ r ______Distance fr m fo ndation-__` _____._. Distance tb nearest lot lige-sf-___-____._ G' <br /> Number of pits-----/_-_---.-__--Lining material_ _--Size: Diameter._+ ,F�r-.._--_Depth-e`.1'_`� ir' \ <br /> Ce ss p ol: Distance from nearest well----------.------Distance from foundation--------------------Lining material_-______.._.__-_____.-_-_..__- <br /> ❑ Size: Diameter--------------------- ----------------Depth------------------------I--------------------------Liquid Capacity--------------------- ----gals. 1 i <br /> Privy:, - Distance from nearest well-------------------------------------------------Distance from nearest building_,__. ------------------- <br /> ❑ ► ' Distance to nearest lot line--------------------- - -- ---- - -- ----- ---------------------------------------------------------------------- ----- <br /> Remodeling and/or repairing (describe)----------------- •• ---------•-------------------------------•------------------------ <br /> t v <br /> ------------- •----------I----------------------------------------------------------------------------------------i-------•-------------------------------- ------------------- --------- <br /> - <br /> ------ ---=-------- ----------------------------------------------------------------------------------------------------------- ------------------------------------------------- ---- ---- <br /> 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 q ulations of the San Joaquin Local Health District. <br /> �. <br /> (Signed) � --------------- - �or Contractar) <br /> : - <br /> BY: = `.--------------------------------•------------------------------------------- ----------(Title). . ...,. ................ -------- <br /> (Plot plan, showing size of lot, location of system in relati o wells, buildings, etc., can be placed on reverse side). <br /> ` FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED—BY ------------------------------------------- DATE... - - ------------------- <br /> REVIEWEDBY--------- UA--------- ----- ---------------------- -------- ---------------------------------------------- DATE---_ZO_!;2------------------------------------------- <br /> BUILDING <br /> --------s---------------------------- <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---- -------------------------- <br /> ---------------------------- <br /> Alterations and/or recommendations:----• -------------- ------------------- --------------------------------------------•---•-•--------------------------•--•---•-•------------------------- <br /> 1 <br /> i <br /> -------------------- -------------'---------------------------------------._-__-.___.------'-----------------------------'------------------------------------------------------------------------------------------------ <br /> r <br /> FINAL INSPECTION BY:.. Date O ------ ---- ---- ------------------------- <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 />