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FOR OFFICE USE: <br /> -- ------------- ...... <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> -----------_------------------------------------------------------------------------------- (Complete in Duplicate) Date Issued <br /> ----------------- -----­-------------- I This Permit Expires 1 Year From Date Issued <br /> __.-_/._ __�1-� <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 AND ..... ................ ---..................... <br /> r <br /> Owner's Name... <br /> ---------------------------------------------- ---------- Phone.................................... <br /> I J2 <br /> Address-- Z�.-ii. <br /> ------------- .....1 7 ... .... ... ---- --------------——— ----------------- <br /> -- ---------- ................................... <br /> Contractor's Name-_--- ---- --------------------------------------------- ........ Phone................................... <br /> Installation will serve: Residence [Apartment House C] Commercial E] Trailer Court F] Motel C] Other [I <br /> Number of living units: __j... Number of bedrooms,-,;-. Number of baths I... Lot size ---__1''S0........................... <br /> Water Supply: Public system E] Community system lePrivate E] Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand [] Gravel F] Sandy Loam E] Clay Loam Clay E] Adobe E] Hardpan ❑ <br /> Previous Application Made: (If yes,date__-------.--_------) No E] New Construction Yes [] No E] FHA/VA: Yes Fj No Ej <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-.--_-._- Distance from foundation--------------------Material------------------------------------------------- <br /> El No. of compartments---------------_--------Size------------------------------Liquid depth-------------------------Capacity----------------------- <br /> A Disposa�Kelcl: Distance from nearest well__-x0_, __.Distance from foundatiqn-----A.0..".....Distance to nearest lot line_________________ <br /> J�.... ... <br /> Number of lines_....... --------------------- ength of each line----so_ Width of trench...2,-/----------------------- <br /> Type of filter materi /4*0(Depth of filter material------ -- ---Total length------s..... <br /> .A................. <br /> Seepage Pit: Distance to nearest well---__- --------------Distance" from foundation....................Distance to nearest lot line-.-__._._..__..._ <br /> El Number of pits----------------------Lining material----------_-----------Size: Diameter-----------_-----------Depth_------_----------__-__-----._-._ <br /> - <br /> Cesspool: Distance from nearest well_---------------Distance from foundation--------------------Lining material------------------------_---....... <br /> 1-71 Size: Diameter--------------------------------------Depth--------------------------------- ---------------.--Liquid Capacityy----------• gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot line---------------------- ------------------------------------------------------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe):---------__-------------------------------------------------------------------------------------------------------­-- .............................. <br /> ..................................................................------_------­------------ ---------------------------- <br /> ----------------------------------------------------------------------------------------------- <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, Stata laws, and rule and regulations of the San oaquin Local Health District. <br /> T the <br /> -- -- ----- --------- <br /> (Signed) --- . .... -- ----- ----------------------------------------------40Wner and/or Contractor) <br /> ----- ------ ----- ----------- <br /> location <br /> ----_----- <br /> By:......C��� -----------------------------------------------------(Title)----------------------------------------------- ------- --------- <br /> v buildings, etc., can be placed on reverse side). <br /> (Plot plan, showing size of lot, location o system it relation to wells, <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED ------------------------------------------------------------ DATE...j(...........43.__.__- <br /> REVIEWED <br /> ...__-REVIEWED BY------------------------_--_---------------------------------------------------------------------------- ................IbATE------------- ---------------------------------------- <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------------—---------------------------_-...... DATE-----------_--------------------------------------------- <br /> Alterationsand/or recommendations:.--------- ------------------------------------------------------------------------ .......................................................................... <br /> ............ --------------------------- ......................... ------------------------------------------------------------------- ........................................................................... <br /> 9., a 0 <br /> ----------------------------------------------------------------------------------------------- ----------........................................................................................------------------------- <br /> ------------------------------------------- ------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------- ------------------------------- <br /> FINAL INSPECTION ------------- <br /> Date------4 ---------------------------------------------- <br /> ------------_---- <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 /> ES 9 REVISED 8-59 314 3-'63 F.P.120. <br />