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FOROFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT Permit No. fJ ._... <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 thew k herein described. <br /> This application is made in compliance with County Ordinance No. 549. f � �J <br /> JOB ADDRESS AND LOCATION_�711".',/,--�---LI LA /-f, , 1 ` .-- f ,-- -- d, -- 1.�/ ---4 P----------------- <br /> Owner's Name----- 6t 5W'9e'--- -------------------------- ---------- --------------- Phone------------------------------------ <br /> --- <br /> . � - ------------------------------------------------------- •- <br /> Address - e. �l�.�, /"- <br /> Contractor's Name-- ---------------------- ---------- Phone----------------------------------- <br /> ----------------------------------------------------------- <br /> Installation will serve: Residence ❑ Apartment House p Commercial railer Court ❑ Motel ❑ Other ❑ <br /> or <br /> Number of living units: Number of bedrooms _'-'__ Number of baths -.f"_ Lot size ----------------------------- r� <br /> Water Supply: Public system ❑ Community system ❑ Private [(Depth to Water Table f -". 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________________ f 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 Tank: Distance from nearest well---7 "-Distance from foundation_.f AL ......Mat fial./--, - f -'---------------- <br /> �� No. of compartments.._2-----------------SizeV ....-.eke.,3_:.Liquid depth___IX.. _----------Capacity_11Z7.411V4*;_1..._ <br /> Disposal Field: Distance from nearest well-_ �7`M_. -Distance from foundation..<.Z.........Distance to nearest lot line.. ....... <br /> 01- Number of lines..... .......... <br /> f__..-._.. -Length of each .. <br /> --- ----- of trench.A2___--- --------------- � <br /> Type of filter materi __Depth of filter material..��.---......Total length-1Z CSO------------------------- <br /> Seepage Pit: Distance to nearest well...................._Distance from foundation--------------------Distance to nearest lot line----------------- <br /> 1:1 Number of pits----------------------Lining material---------- ----------(Size: Diameter----------------------.Depth----------------------------_-.-- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-_.---------------- Lining material-.-_.___....__._________--------. <br /> ize: Diameter--------------------------------------Dept h--------- ------------------------------------------Liquid Ca _acTit _.-------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------._....--------------. <br /> ❑ Distance to nearest lot line-------------- ------------------------------------------------------------------------------------------- <br /> 4 Remodeling and/or repairing (describe): - -------------------------------------------------- <br /> --------­---­---------- <br /> -------------------------------------------------------------------------------------------- ----------------4-------------------- - --------------------- <br /> ------------------------------------- <br /> -----------------------------------------------------------•----------------------------------------------••----•------------------------ --------------------------------------------------------------------- ----------- <br /> r <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 District. <br /> (Signed)--------------- -------------- --- ----- --- -- -- ------------ ---------------.._( for Contractor) <br /> By:------------------------------------------------------------ -----------------------------(Title)-� ------------------------------------- <br /> (Plot <br /> '----------------- - -------------- <br /> (Plot plan, showing size of lot, location of s t in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY----- -------------------- -- - --------- ------ ------- ------- -------------------------- DATE------------------------------------------------------- <br /> ---------------------------BY-------------------------- ----------------- - - ------------------ - ------ ---------- -- ----------- DATE----------------------------------------- <br /> BUILDING PERMIT ISSUED---•-------- --------------------------------------------------�. DATE-------- ------- ------ <br /> Alterations and/or recommendations: - -----------------------• -------------------------- <br /> ------------------------------------------------------------------------------------------------ - ---------------- <br /> -----•-------------•-------------------------------------------------------------------------------------------------------------------------- -- ---------------------------- ------ - ----- ----------------------------------------------------- <br /> - <br /> --------------- --------------------- ------------------------------------------------------------------------------------------------------ ---------------------------------------­_ ---------------------------- <br /> -------------------------------- --------------------------- ----- ------ -- ---------------------------- --------------------------- -------- ----------- - ------------------------------ <br /> �� ..- ,� <br /> FINAL INSPECTION BY: r - Date ---- - - ---------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hasellon Av*. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi, California Manteca,California Tracy,California <br /> I <br />