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FOR OFFICE USE: <br /> --------------------- -------------- o <br /> APPLICATION FOR SANITATION PERMIT Permit No. ...X1. <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 the work herein described. <br /> This application is made in compliance with County Ordinanc No. 549. <br /> JOB ADDRESS A OC ION'f / ti Q z (QoI P+. `'� ^_._ 1a ------------------ <br /> Owner s Name------­--------- --- -------- -•------------ --•-- --------• ---- ------- --------------- -------------- Phone--------------------- <br /> --- ------------- <br /> • 1 <br /> Address---------- ----� .... .............. . .... ......•-•-- ... ---•-------- ------. ---- ---------•-----------• .................................. <br /> r . <br /> Contractor's Name �� ---•-------------- Phone <br /> ------ ------- --------- --- ------- ... - <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [3 Other <br /> Number of living units: :--__ Number of bedrooms-!:-_ Number 'f baths __1-.- Lot size -------- -- ------ <br /> Water Supply: Public system E] Community system El Private [Depth to Water Table ........ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe �arclpan ❑ <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 /> mat <br /> Septi ank: Distance from nearest well-----------------Distance,fro Foundation------l-.0-----...Mat ri-.----d1/�-- ---------� <br /> No. of compartments--_-"�__---'---Size_,3__.... ------,1 —9 Liquid depth--.___-�'-/---_-___-Capacity...�O A___ <br /> Dispos Field: Distance from nearest well----40----- <br /> -Distance from foundation-----/_.fl---------Distance to nearest lot line <br /> ..?....._ ...... <br /> Number of lines-----------/------________------Length of each line__..____,6®_`---------Width of trench----�"_------------------------ <br /> Type of filter material-__.---- ---.-Depth of filter material --_l1__._-_-_..Total length___-_SE'--- ........................ <br /> Page I H44 Distance to nearest well------/._0...---Distance from foundation-_- Distance to nearest lot line---->r--_....... <br /> ❑ Number of pits--.----_f _-..__--Lining material---_ .�i----Size: Dre �er �- � <br /> Depth------ --------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.--_._.-_._--_-----__.----________-. <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Stat s, and rules and reg ion of the San Joaquin Local Health District. <br /> (Signed)--- --- --- -- r and/or Contractor) <br /> BY�---- -----------`----------- -- ---- (Title)-------------------------- ---------------- - - ---- --------- <br /> By:- <br /> plan, showing size of lot, location of systerrir in relatio to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- ------- ------------------------------------------------------ DATE_':.6/ __'G�-------------------------------- <br /> REVIEWEDBY-----------------------------------------------------------------------------_._---------------------------------------- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED------------_---- --------------------------------------------------------------- ------------------ DATE------------------------------ ------------------------------ <br /> Alterations and/or recommendations----------------------- --------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------•----- -------------------- ----------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------- --------------------- ------------------------- ------------------------------------------- ---------------------------------------------------------------------- <br /> FINAL INSPECTION BY:..--1,14-14�- Date-----' - 3 --��... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stoodon,California Lodi,California Manteca,California Tracy,California <br /> F.P.C C. <br />