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FOR OFFICE USE: <br /> ------------ ------ <br /> APPLICATION FOR SANITATION PERMIT Permit No. ..f.................. <br /> ------------------ ----------------- --------------- (Complete in Duplicate) <br /> ------------------------------------------------------ -- <br /> ______.__- _----- This Permit Expires 1 Year From Date Issued Date issued <br /> I <br /> Application is hereby made to the San Joaquin Local Heal}h District for a permit to construct and install the work herein described. <br /> This appiicatiori is made in compliance with County Ordinance No. 549. <br /> ll ,- -------- --------------•---•---------- -•-----....._...------------ --- .- <br /> JOBi ADDRESS AND LO TION--- -� �f= , _ <br /> Owner's Name ---- C df^YL-------------- -•-----•-------- --�--- Phone�Q...-- f ` <br /> ---Address.----•--------•---------•-•-•- ---------------------•-- ----- --•-•----------------- -------------•---------------...-------..._.. <br /> Contractor's Name--- ----------- '�'_' ' ( c _--•----•-•-----------------------------=4 ----- --- Phone----------------------------------- <br /> Installation will serve: 'Residence Apartment House ❑ Commercial ❑� Trailer Court.'❑ Motel❑ . Other ❑ <br /> Number of living units: _j___ Number of bedrooms _7--Number of baths __ __ Lot size . <br /> Water Supply: Public system,.& Community system ❑ 'Private ❑ Dept tc'Water Table ft, , <br /> Character of soil to a depth of 3 feet:- Sand ❑ Gravel ❑ Sandy Loam 0 Gley Loam ❑ ,Clay F-1 Adobe, Hardpan C] <br /> Previous Application Made: (If yes,date-----------__-------f Now New Construction: Yes•❑- No FHA/VA: Yes ❑ NoA <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: . <br /> `(No septic tank'or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic T kv, Distance from nearest well-----------------Distance from foundation--------------------Material_____-__'_____.________.___-__--_-__._--__-____. <br /> No. of compartments--------------------------Size--------------- ---------------Liquid depth�'.i' ---------------Capacity--•-------------------- <br /> Disp sal Field: Distance from nearest welL_______________Distance from foundation-----------F-------Distance to nearest lot line----------------- <br /> Number of lines---------------------- ------Length of each line--------------------- ------- Width of trench--•------_---------------------..- <br /> Type of filter material____._*-----------------Depth of filter material--------------_~"__-_Total length_________________:____...___`f_____r_____ <br /> Seepage Pit: Distance to nearest well__-_Distance from foundation--,-/-46---- stance nearest lot line__._S- -i__ i <br /> Number of pits------ --------Lining material_ .- ` O"e: <br /> Diamet-er_-.__.i__X..2�__.Depth____ 7________.__ r <br /> Cesspool: Distance <br /> from nearest well_---�------ Distance from;foundation _--"--_ — <br /> _ _Lor.ng material______________________. <br /> pDam - Dep ------------------------ <br /> - :-'-_LiquidCapacity. <br /> �O <br /> � <br /> Capacity----------------------------gals. <br /> Privy: Distance from nearest well ________________________..____-_----__------------------------------------------ D?istance from nearest building.___-____________________-_--__________- t <br /> Distance to nearest lot line--------------------------------------------- <br /> k ' <br /> Remodeling and/or repairing (describe):----------•,--------------------------------:_�------------•---------------�------ -----•----------------------------------------------- <br /> --------------•---------------------- `•-------- <br /> -- <br /> ----------h---------------------------I----------"----------------•--•---------------'-----------------•---------------- - � ----r'._' -. ----------------------- ------------------ --- - <br /> P` <br /> -•------------------------•---------- ------------•------------------•-----------•---------------------------------------------`--------------------------------------------------------------- ----------- ------ ------- <br /> -----------------------------------------------------------------------•------------------..-...------------------------------------------•-------'-•---------_---------------------------••---------- ---------- <br /> f I hereby certify that I have pre r thisdapplication and that the work will'be,done in accordance with San Joaquin County <br /> ordinances, S w nd rules and tions.of the San Joaquin Local Health District. , <br /> {Signed).- -- -:��'Ch �� (Owner andfor-Eontacl ' <br /> By:--------------------------------------------- '------------------ ----------------- -------------------------------•--•---------(Title)------------------------------------ ------ - ------------- <br /> '[Plot plan, showing size of lot, 'location of system in relation to wells, building., can.be.•placed on reverse side). <br /> FOR DEPARTMENT USE ONLY 'r <br /> APPLICATION ACCEPTED BY------ < - --- ---- ------------------ - ----------- DATE----- ---------------- ' . <br /> REVIEWEDBY------------------------------------------------- --- ------------------------- ---------------------------------------------- DATE------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------- ----- --•------------ DATE---------------------------------------------- 1_, <br /> Alterations and/or recommendations:-: --------------------------------------- -----'----- <br /> -------------------------------------------------------------------=--------------------------------------------------------------------------------••-••--------------------------------------------:----------------------- <br /> --------------- -------------------------------`---•---- ............................... ------­-----------------Z --------------------------------------------------------------------- -------- <br /> FINAL INSPECTION BY:. �... _. J Date-----------G � ---/-- -------------------------- <br /> SAN <br /> -------------- ----a--SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> EB-9 REVISM 0.69 F.P.CM 2M 6.60 - f <br />