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FOR OFF5E USE: <br />,.�s ' �'ya ----/,/ -_---------- ` <br /> '/S APPLICATION FOR SANITATION PERMIT Permit No. .t. <br /> o----------------- <br />---------------_�-(_-�_�- ---_ (Complete in Duplicate) 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 Ordinance No. S49. <br /> JOB ADDRESS A O _______ ____ <br /> -----•---------------------------------------------------------- <br /> Phone------------------------------------ <br /> Owner's Name---- ------------- ---------------------------- -------------------------------------------- <br /> Address............... <br /> ----------------------------------------Address--------------- '-•------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> Contractor's Name --- - -------------------------•---------------- ------ --------------------------- - Phone <br /> - --- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -/_ Number of bedrooms _A• Number of baths __/--- Lot size �I-VI J-•------------------------ <br /> Water Supply: Public system 2110community system ❑ Private ❑ Depth to Water Table�r� ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe f ?—'Sardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No &--New Construction: Yes ❑ No 'FHA/VA: Yes ❑ No 0►— <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tan : . Distance from nearest well_________________Distance from foundation--------------------Material------------.----------------------.-_-.--------- <br /> /-j i!5y� No. of compartments---------------•---......Size-------------------------------Liquid depth-------------- -----------Capacity----------------------- <br /> Diissposal FkId: Distance from nearest well_---.__-_-_..._Distance from foundation.._-__--__-_____._-Distance to nearest lot line---------------_ <br /> st Number of lines-----------------------------------Length of each line------------------------------Width of trench------ ---------------------------- <br /> Type of filter material-------------------------Depth of filter material----------------------- length___________________________._-____-__._ <br /> Seepage Pit: Distance to nearest well_._---__-_.-.___Distance fro fo dation__ __ ___________. <br /> Dista a to nearest lot lige__ <br /> Number of pits-------/_-.____-_Lining material____ -jVjP&CSize: Diameter__- <br /> Cessp� Distance from nearest well-----------------Dstance from foundation--------------------Lining material----------------------___--_- <br /> ❑ Size: Diameter------------------------------ -------Depth------ --------------------------- -------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well--------------------------------------------- <br /> ----Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot line---------------------------------- ------------------------------------ ------------•--------------------------------------------------------- <br /> ------------------------•------------------------------- <br /> Remodeling and/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, aandrulls and reggu�_lattions of the San Joaquin Local Health District. <br /> (Si ned_ ✓ fE%�Y-------- ----- - -(Owner and/or Contractor) <br /> 9 ) -------------------- ------------ - <br /> By:-------------------------- - - - ---- --- 9 ------------Titlep_ - <br /> -- - -- -- ----------------------- - <br /> (Plot plan, showing size of lot, location of system in r ion to wells, buildings, etc., can be laced on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.----.- --- ------------------- <br /> ------------------------ DATE------- '2����=(�`S-J-------------------- <br /> ----------------------- - <br /> REVIEWEDBY-------------------------------------------- ----- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED----------------------- --------------------------------------- -------- ----- DATE------------------------------------------------------------- <br /> Alteration,sand/ r co mends ions: ----- ------------------------------------------- ....................................- ----=--=-------------- <br /> dr 0,0 <br /> •- ----------- - f --------- ----------------- --------------- ------------------ ---------------------------------------------------------------- <br /> ----- ------------------------------------------- ---------------------------------- ----------------------- ---------- <br /> l-N <br /> FINAL INSPECTION BY----------------- -------------- Date------.... - ` <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.CO. <br />