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0 f� d� APPLICATION FOR SANITATION PERMIT Permit No. -- �--__------------ <br /> (Complete in Duplicate) Date Issued <br /> V` <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�A�NDy�LOCATIO <br /> -- J& -- ---------------------------------------------------------•-- <br /> Owner's Name__"-�!/sem AW- Phone <br /> Address --------- --------------------- <br /> ��''-- `` <br /> Contractors Name-------- + ' J~ c -------- -- Phone <br /> Installation will serve: Residence ❑ Apartment House El Commercial E] Trailer Court ❑ Motel Other ❑ <br /> Number of living units: _X Number of bedrooms __.1-- Number of baths _%___ Lot size`_ _ /a --.---•----------------------- <br /> Water Supply: Public system El Community system El Private Depth to Water Table _ _0 ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 8--'Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes ❑ No ?R— FHA/VA: Yes ❑ No [I}� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: l <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> f <br /> 4erank: <br /> Distance from nearest well________._______Distance from foundation__._______________Material________--------____._._______-________._.__-___. <br /> ' No. of compartments-------------- ----------Size----------------------------=---Liquid depth---------------- ---------Capacity----------------------- <br /> i <br /> ________Distance to nearest lot line___- -_ <br /> Disposal, Field: Distance from nearest weli_../j�0__Distance from foundation____ - ��---- <br /> [ 'r Number of lines---------/------------ ength of each line----- P_ -----��.._.Width of trench.___ _' _�__________________ <br /> ------------ ® <br /> Type of filter material_ epth of filter materia!___. a_____�___Total length--__- e+s (; <br /> �: }. "�. <br /> �F. Distance to nearest well___�1��---Distance from f�dation____�__...____..Dista t� to nearest lot line_ � <br /> ®► Number of pits-------/------------Lining material-_AEOJ5.I_E�__Size: Diameter____' ____-_____Depth_____ _ _____________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------.-----Lining material________.____._______---------______. 0 <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-----------__ ----------------------------------Distance from nearest building._-_______________________------_____._. <br /> ❑ Distance to nearest lot line----- ----------- ----------------••---------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe)______________ _ _ <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, rules and re lations of the San JoaquVLoal Health District. <br /> �---------------------(�r Contractor) <br /> (Signed)---------- --- -- ----- <br /> ---------------- <br /> By:----- ----------•--------------------------- ----------------------------------------(Title) ,/✓6 � <br /> (Plot plan, showing size of lot, locatio f system in relation to wells, buildings, etc., can be placed on revers ide). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY--------------------------- - ------------------------------------------------------------------- DATE----------------------- <br /> iREVIEWED BY--------------------------------- -- - --------------------- ------------------------- DATE------------------ --- 1 ------- ---------- <br /> BUILDINGPERMIT ISSUED------------------- -- --------------------------------------------- -----------------• DATE- `---------------------•------------------- <br /> Aiferationsand/or recommendations:--- --- ----------------------------------------•------------------------------------------ - •---- ----------------------------------------11 <br /> ------ <br /> _____________________________________r___________ ___________.____-_ ____.__--_---_-_______________ -------- <br /> � ' r'4a "`�, t� -- ---------- --- - -------- <br /> - "r--- - --- --- <br /> -� --. <br /> FINAL INSPECTION BY:. ----- ---------•- ------- --- Date------ <br /> SAN JOAQUIN LC AL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5-9-2M Revisea 1-57 F.P.CO. <br /> i <br />