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FOR OFFICE USE: <br />------------------ ---------------- -------- ------------ APPLICATION FOR SANITATION PERMIT Permit No. <br /> --- _ (Complete-in Duplicate) <br />-------------------------- --- --- ----- <br /> - ------- <br />--------- ­------- __ Date Issued <br />--- -------------- ----- - -------- ----------------- --- This Permit Expires I 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. 549. <br /> JOBADDRESS AND OCATION---- ------- -------- - -- ---------------- -------------------------------------------------------------------------------------------- <br /> -- -- --- Phone------------------------------------ <br /> Owner's Name -------------- ...... --- -------------- --------------------------- <br /> Address..........:�X .. ---------------------------I--------------------------------------------------------------------------------------------------------------- ........................................... <br /> T Phone <br /> ...... ---------------------------- <br /> Contractor's Name---------- -----­---------------------------------------- <br /> Installation will serve: Residence Le-Apartment House I-] Commercial E] Trailer Court E] Motel [3 Other El <br /> Number of living units: -_ _/__ Number of bedrooms ---:9Number of baths _/_--.- Lot size _-__2_-4` ' ----- _______________________________ <br /> Water Supply: Public system E] Community system E] Private ILS epth to Water Table _2�_(_)ft <br /> Character of soil to a depth of 3 feet- Sand Ej Gravel M Sandy Loam El Clay Loam Ej Clay [] Adobe 0--Hardpan 0 <br /> Previous Application Made: (If yes,date______---__-__.- ) No E]f" New Construction: Yes 0 No f5­FHA/VA: Yes 0 No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septi <br /> k Distance from nearest well_________________Distance from foundation------------------..Material -------------- --------------------------------- <br /> No. of compartments---------- --------------Size------------------------------Liquid depth--------- ------- ------- Capacity----------------------- <br /> -1 '6-1------ <br /> Disposal FieV. Distance from nearest well_________________Distance from foundation_x;?_07� ......Distance to nearest lot line... <br /> El- Number of lines_.-__---_I-.-._---_-__-__.-._ <br /> -------I------------------.-.-Length of each line-- ----6 ----.________.Width of trench.... ..�_f........I------------- <br /> Type of filter material C___.__--Depth of filter material----- _____Total length----v''. --------------------------- <br /> Seepage Pit: Distance to nearest well./�_O-------------Distance from foundation--- .........Distance to nearest lot line--- <br /> H-' Number of pits__1_______._.Lining material----_1/71r_(AC__ Size: Diameter.....3_3------------Depth-----!?--J--------- <br /> Cesspool: Distance from nearest well ________________Distance from foundation_.._____._____ _.Lining material------------------------------------- <br /> F Size: Diameter- -- --------- ----- ----------------Depth------------------------------ ---------------------Liquid Capacity--------------------------gals. <br /> Privy: Distance from nearest well---------------------------------------------- --Distance from nearest building.______-_.-__---____----_--- .-____.. <br /> ❑ <br /> uilding----------------------------------------- <br /> f-1 Distance to nearest lot line------------------ -------------------------------------------_---- ------------------------------------------------------------------_. <br /> Remodelingand/or repairing (describe):------ ---------------------------------------------------------------------------------------- -------- --------------------------------------------- <br /> -----------------------------------------­---------------------------------------------------------------------------------------------------------------­------------------- -------------------­--------- ------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I-------------- <br /> -------- -------------------------------------------------------------------------------------------------------------------------------------I---------------------------------------------------------- --------------- <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 regulations of the San Joaquin Local Health District. <br /> ico (Owner and/or Contractor) <br /> ----------------------------- ------------------------------ <br /> (Signed)---------------------- --------- <br /> - --------- <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 /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------------- ------------- --- -------------- DATE---------- ---------------- <br /> REVIEWEDBY--------------------------------------------- --------- -------- ----------------------------------------- ------------ ----- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED---------- ------------------------_ --------------------------------------------------------------- DATE-----------------------------------_----------------------- <br /> Alterationsand/or recommendations------------------ ----___--------------------------------- - ------------------------------------------------------------------------------------------- <br /> ---------------------- <br /> ----------------__------------------------------------------------------------------------ <br /> ----------------------------------_----------------------•------- ------------ ------------------------------------------------------------ -...................----- <br /> - <br /> ------------------------- ------------ -----------------------------------1-------------------------------------------------------------------------- ------------------------------------------ --------------- <br /> -------------------------------------------------- ---------------- ------------------------------------------------------ ------------------------------------------ ----------- -­- ------------------------- <br /> -------------- ----------- -----------­---- ---------------------------------- --------------___--------------------------------- -------------------- ------------------------------------------------------- <br /> FINAL <br /> ----------- ------------------------------- <br /> FINAL INSPECTION BY:----- —-­--------------- Date-----------5;;- <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 /> E.H.9 2M 1-67 Vanguard Press <br />