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/ FOR OFFICE USE: <br /> -------.-43 4--------------------------- -------- <br /> ---------------------------_..---.------ - ----------- APPLICATION FOR SANITATION PERMIT Permit No. .. <br /> --------------------------­__- ...-..-_.._- (Complete-in Duplicate) <br /> ------------------------------------------------ Date Issued <br /> ._.. This Permit Ex ires 1 Year From Date Issued <br /> _____.___./-__7_ <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. It <br /> JOB ADDRESS AND LOC ION___._ _ _��___ ___w ._. _ _ <br /> --------------------------- --------------------------------------------------------------- <br /> Owner's Name__.- •- ------------•-----------•--------•-•---------- ------------------------------ ------------------._.. Phone--------------------•--------------- <br /> Contractor's Name 75-----•--- -- <br /> -------------------------------- ------- ------------------------------------ <br /> ----------- Phone------------------------------------ <br /> l Installation will serve: Residence [A-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> e Number of living units: --I-- Number of bedrooms I--- Number of baths.__'1-._ Lot size ----2-Alg-_ -_______________________ <br /> Water Supply: Public system ❑ Community system ❑ Private [Er-'Nepth to Water Table ft <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 25'Hardpan ❑ <br /> Previous Application Made: (If yes,date_.................. ) No El_' New Construction: Yes ❑ No � FHA/VA: Yes ❑ No [g— <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septi Ta' Distance from nearest well_..............Distance from foundation_____--.----_._-_.Material -------------_._.------.----------------------- <br /> a��lel' No. of compartments----------------------..Size------------------- -----------Liquid depfih -- --- --------Capacity-------------- �------ <br /> Disposal Fi Distance from nearest well-.-. .-...-Distance from foundation---! <br /> ---------------Distance to nearest lo; line_______-___. ' <br /> _.-._--_Length of each line_.%� <br /> Number of lines.------�-- ----. . `�0-----------------------Width of trench- ,.2-'9------------------.._ <br /> Type of filter material._._: ��__C--_--Depth of filter material__/Y_`'-----------Total length------- <br /> .( _._____.____----------------- <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----__--.___---____-____..______-_-. --r <br /> ❑ Size: Diameter. .- -------------- --- -----------Deoth- -------- - - - -----------------------------------Liquid Capacity-------------- -- --..gals. �J <br /> Privy: Distance from"nearest well______________________________ --._._Distance from nearest building--------------------------------..._____.- <br /> ❑ Distance to nearest lot line --------------------- ------------------- -------------------------- <br /> Remodeling and/or repairing {describe)--------- ------ --------------------------------------------------••---------------------------- • :--------------------------------------- <br /> ----------------------- ---------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin Count <br /> ordinances, State laws, rules and..reg ation of the San Joaquin Local Health District. <br /> {7 <br /> t (Signed)------------------ -- -- -- -------- --- - -- - ------ - ----- ----- - - - ------------------- ----- -----•---------- - ----------- ----- -- -.(Owner and/or Contractor) <br /> If <br /> By:-------------------------------- - ---------•--- ---------- - ----- -- -- --- ---------------------------------------(Title)----------------- � I <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> j FOR DEPARTMENT USE ONLY <br /> ` APPLICATION ACCEPTED BY y' - - - ------ DATE-- )---z-A---6---2--- <br /> y <br /> REVIEWEDBY------ ---------------•---------- ---- - - ---- ------- -- ------- --- ------------- -----------=-------------------------- DATE <br /> BUILDING PERMIT ISSUED-------- -- -------------- '------------------------- DATE--------------------- <br /> Alterations and/or recommendations------------------ ------------------------------ .. <br /> -----•------------ - --•- ----.. <br /> lm <br /> 4 <br /> _ ________________________ <br /> f <br /> t ------------------------------------- <br /> �1- � _ <br /> FINAL INSPECTION'BY: -------------------- ----------------' #° Date---------------------------------- -- - - ------ -------------- ----------- <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 /> E.H.9 2M 1.67 Vanguard Press <br />