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FOR OFFICE USE: <br /> �f'° ------- ------'-`---�-- <br /> � <br />-------- -------------------------- <br /> APPLICATION FOR ,SANITATION PERMIT Permit No. .. . . ®� <br /> '._. <br /> ----------------- ------ <br /> � <br /> _ _._ _- - ------- -- (Complete in Duplicate) <br /> ___-_._________.__. This Permit Expires 1 Year From Date Issued 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 Ordinance N . 549. <br /> r -- ------ ---- - <br /> JOB ADDRESS AN LOC TI� .��`'�--3 <br /> Owner's Name--------��-•ILr"moi- ------------------------------------ Phone-------------------------------- <br /> ---------------------------------------------------------------- <br /> ----------------------------------------Address--------------------------—i . __- <br /> Contractor's Name-------' ---'�-�---�----------- ------------------------------------------------------------------ ------ Phone----------------------------------- <br /> Installation will serve: Residence � Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _.�__-_ Number of bedrooms _.,2- Number of baths _t-_-_ Lot size ---- _----------------------- <br /> Water Supply: Public system ga-Community system ❑ Private ❑ Depth to Water Table -4.0 ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2iJ Iardpan ❑ <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 /> Sep6r* pTlan Distance from nearest well-----------------Distance from foundation--------------------Material--------------------------------__-_.--._____--_. <br /> No. of compartments--- -------------------Size------------------------- -----Liquid depth------------------------- Capacity---------5;----or---Dis Dista Distance from nearest well__ �_____._Distance from foundation_l0__ v <br /> __._____.Distance to nearest lot line_________________ <br /> Number of lines_-_-___/____ Length of each line------3D__________________Width of trench-__i?�-___-----___--._-__--__- <br /> T e of filter materia______.__C _-_-__De th of filter material___l�r k________Total length___•3f'_'_______________.._____ <br /> YP ' �l0 _ P ---- <br /> Seeps .Pit: Distance to nearest well----- ----------------Distance_jLom foundation__14-----------Distance to nearest lot line-- __7-----.- <br /> Number of pits____.(--------.-_ __Lining material__)X0_C-_&.__Size: Diameter.___.33--------Depth____-.--_-�___.-------- Y <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 /> Ch <br /> Remodelingand/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, and rules and re lations of th2 San Joaq in Local Health District. <br /> (Signed)--------------------------------------------- -----------------------------------------------------------(Owner and/or Contractor) <br /> BY:--------------------------------------------------------------------------------- ------------------------------------------------(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------------ -f- ----------------------------- DATE--------/-:r_—/'= ---------------- <br /> REVIEWEDBY---------------------------------- -------- -------------------------------------------------------------------------- DATE--------------- ------------------------------------------ <br /> BUILDINGPERMIT ISSUED------------------ -------------------------------------------------------------------------------- DATE------ ------------------------------------------------ <br /> Alterationsand/or recommendations----------------- ---------------------------------------------------------------------------------------------------------------------------------- <br /> - _------ ---------- ------------------------------------------ ------------------------------------------------------ ------- ------------------ <br /> ------------------------------------ ---------------------------------- --- ------- --------------- ----------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------•-------------- -------------------------------------------------------------- ------------------ ---------------------------- ------------------------------ ------------ <br /> ------------­--­-------1-----------------1­ <br /> --------------------------------------------------------.,----------------------------- -------------------------------- ---------------------- -------- ---------------------------- ------------------------------------------ <br /> FINAL INSPECTION BY:----- --- Date-----------7_ 1e'-0_?Z ------------------------- <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 /> F.P.CC. <br />