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FOR OFFICE USE: <br /> - ---------- ------------------------- ------ <br /> '_______r' APPLICATION FOR SANITATION PERMIT Permit No. ........................ <br /> r <br /> ---------------- <br /> ------------ --------- =- F o - ------------ (Complete in Duplicate) ` <br /> ---------------- ---- ---------------------------- -- I This Permit Expires 1 Year From Date Issued <br /> Date•Issued1.�� . <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 )LOCATIO ... :.a<--L. <br /> Owner's Name------•' --�G�• � . - - - - PhoneZZL(2-G*� Q <br /> Address-----•----•-------•••- --/ <br /> Contractor's Name -- - -------- Phone................................... <br /> Installation will serve: Residence 2--Xpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __1___- Number of bedrooms _ Number of baths ----L Lot size __-_6-0-K.1_�?_b______________________________ <br /> Water Supply: Pubd,ic,system [ ommunity system 0 Private ❑ Depth to Water Table ------ <br /> _ ft. <br /> Character of soil to a ic}epth of 3 feet: Sand ❑ 'Grav,,el ❑ San y Loam F71Clay Loam ❑ Clay dobe �ardpan F]Previous Application Made: (If yes,date________ _______ ) No New Construction: Yes ET-__N�❑ FHA/VA: Yes ❑ No R <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic <br /> �,Tank: Distance from nearest well_-----_-__--__i_Distance from foundation-------------_-___.Material--___.-- <br /> E��1 _TaO <br /> No. of compartments--------- ---- -----Size-------•-----------------------Liquid depth--------------_ --------Capacity-----------------�--- <br /> Dispo,s,a.,�l.�Field: Distance from nearest well__ _:_Distance from foundation__ . _IQ_- Distance to nearest lot line_-_-3_ <br /> Number of lines LengthZnS�li 7W-----` ..Width of trench f <br /> jI aa <br /> gnat Type of filter material(,x--ll�Depth of filter material-__.-__._fo______-Total length_____-.----2_6Q_--_-_�/y <br /> -�14-V <br /> Seepage Pit: Distance to nearest well __________________Distance from foundation_______..__________.Distance to nearest lot line----------------- <br /> 1771 <br /> -__---._ ___.-_❑ Number of pits--.-_ ___ ------- __Lining material-_._ ------------Size: Diameter-------------- --- ----Depth--------------------------------- <br /> Cesspool: <br /> .____------ ----._.-._._ -_-_Cesspool: Distance from nearest well ----------------Distance from foundation--------------------Lining material________________ _________________. <br /> ❑ Size: Diameter- __ .--------_ <br /> ----------------Depth--------------- -----------------------------------Liquid Capacity----------------------------gals. V) <br /> Privy: Distance from nearest well-._.___-________------------------------------------------ -_ __Distance from nearest building • <br /> ❑ Distance to nearest lot line------____________________-_ <br /> Remodeli yd/or repairing (clescribe):,�! e-- --- j <br /> •-------- <br /> ------------ <br /> ------------------ ---------------------------------------------------------------­----------------- ------------------------------------------------- -------------------------------------------------------- <br /> I hereby certify that I have prepared this application and +hat the werk.,will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rul =;� <br /> the S aquin 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------ ----------------------------------------------------------------------------- DATE------ <br /> REVIEWEDBY--------------------------------------------------------- --------------------- -------------------------------------------- DATE---- <br /> BUILDING PERMIT ISSUED----------------------------------- ------ DATE--------------- <br /> Alterations and/or re'commendations-------------------------------------------- <br /> ------------------------------ <br /> ---------- ------ ---------------------------------------------------------------------------------- ---------------------------------- ------ <br /> ----------------- --------------------- --- ------------------------------------------------------------- --------------------------------------------------------------------------- <br /> ---------------------- ------------------- ------------------------------------------------------------ ------------------_-------------------------------- <br /> ------------ ------ -------------------------- ----------- -------------------- ----------------------------- ----------------- ----------------- <br /> FINAL INSPECTION BY:.----Ci _.. --- --------- ------------ ------ Date----- <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 />