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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> -------------------- ------ (Complete in Duplicate) <br /> Date Issued <br /> --------------------------------------------------------- I This Permit Expires 1 Year From Date Issued W01104 <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. (� r <br /> JOB ADDRESS AND CATION_,-Y_lK--- <br /> Owner's Name------- ......G...• . ----- /. '-------------- ------------------------------------ Phone--------- <br /> Address••-•--... - "' � c�. C..�'------------------ <br /> Contractor's Name--------- ----- (�"` --------------- Phone................................... <br /> -----`,y-� <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -----1_ Number of bedrooms____ Number of baths Lot size ----A "-" `_ <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ..------ 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_________ __--------) 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 ank: Distance from nearest well_____c��_____Distance/ffom foundation___--/__C2________-M terial.___ -a - __r_____________�c-__.___ <br /> Ee No. of compartments_____Y________......Sizeyl___�L_-�. X.S_-Liquid depth-_-"►r-------________---Capacity-�p.__-_- <br /> Dispos�l Field: Distance from nearest well___��______Distance from foundation__../0:__---------Distance to nearest lot line57_____ ...... <br /> Number of lines---------- --------------------Length of each line70_-__7. `1n_.9'a__'-Width of trench ___2:__I__,_____________________ <br /> � - _ � f <br /> Type of filter materiaL___�_�_x____.____Depth of filter material---L_7^__-__ _______TOtal length__ . Q............................ <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 /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- <br /> 0 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 /> ----------------------------------------------- <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, and ules and regulations of the San Joaquin Local Health District. <br /> (Signed) ------------------------0_1 <br /> ----------- -- ------- ------- --------------------------------------- and/or Contractor <br /> BY: ... .Z -- ---------- --------•-.-------------------------- (Title) - - -- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ _ - . -- ------------ ---- <br /> -- <br /> DATE___ <br /> ___.. -REVIEWED BY--------------------------------------------- -------------- ------------- ----------------------------- DATE--------------------------------------•-------------------- <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------------____-------------------------------- DATE----- ------------------------------------------------------- <br /> Alterationsand/or recommendations---------------- -----------------------------------------------------------•------------------•--------------------------------------------------_---------- <br /> ----------------------------------------------------------------------- -------------------------------- •---------------------_-------------------------------------------------------------------------------------- <br /> --------------------- --------------------------------- -------------------------------------------------------------------- ------------------------------------------..------------------•----------------------- <br /> --------------------------------------------------------- ------------- ---------------------------------------------------------------------------------------------------------------•--------------- ---------------------- <br /> --•---------------- -­------------------- ------------- ------------------------------------- ------------------------------------------------------------------•----------------------------- ------ <br /> FINAL INSPECTION BY:.. _ -. -__.___. __:_ <br /> --------- ----------- Date---------- Z/.---6-`-------------- ----------- ---------- <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 />