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FOR OFFICE USE: <br /> ------------- ------------- <br /> ----------------- ----------- - APPLICATION FOR SANITATION PERMIT Permit No. c/ <br /> - <br /> ---------------­­­--------------------- -------- (Complete-in Duplicate) Date Issued -7 <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. 549. <br /> JOB ADDRESS AND LOCATION-------------- --------- - _------.--- `�J- �- <br /> Owner's Name--•---.f7- -------_------------------ ----------------------- Phone------------------------------------ <br /> Address.............. --------------------------------------------------------------------------- <br /> Contractor's Name----- ...... ----------------------------- ---------------- ................ Phone-----------------------•---------- <br /> Installation will serve: Residence gj-,Apartment House E] Commercial F] Trailer Court E] Motel ❑ Other El <br /> Number of living units: _/__ Number of bedrooms__ Number of baths _/--- Lot size Z 12 --------------------------- <br /> Water Supply: Public system E] Community system E] Private E-Septh to Water Table-,O�_ _ ft <br /> Character of soil to a depth of 3 feet- Sand k-Gravel [] Sandy Loam E] Clay Loam E] Clay E] Adobe C] Hardpan E] <br /> Previous Application Made: (If yes,date----- ------------- ) No&' New Construction: Yes [] No RB- THA/VA: Yes�--No El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: - Distance from nearest well_________________Distance from foundation--------------------Material ------- ------------- ----------------- ........ <br /> No. of compartments-------------------------Size---------------- --- ---- ---Liquid depth--------- ----- - ------- Capacity----------------------- <br /> 'r de_ -4 <br /> Disposal Field: Distance from nearest well__ti�o-----Distance from foundation.-19-0----- Distance to nearest lot line-%------`- <br /> Number of lines <br /> z <br /> ength of each line__;;,�$ --------_Width of trench,;-----` <br /> 47,0'r 0' <br /> Type of filter material-42 74-epth of filter material------001*'jV-----------Total length__oo'_OQp_-------------------- <br /> 1KSeepage Pit: Distance to nearest well---------------------Distance from foundation--------------------Distance to nearest lot line---__---_-_-___-. <br /> ❑ <br /> ine----------------- <br /> E] Number of pits...------------.---.Lining material-__-_-._..----____ Size: Diameter-_.__---__-.____.___Depth._.-_._-.-_-_-------------_-- q <br /> Cesspool: Distance from nearest well ----------------Distance from foundation---- -----------. .1ining material-...-..-._.--.-.--.--_-_.--.______--_. <br /> ❑ <br /> aterial-----_----------------------------- <br /> El Size: Diameter- -- -------------- - ..............Depth----- ----------------- ........ ---------- -------Liquid Capacity------------------ ---------gals. <br /> Privy: Distance from nearest well... ---------------- -----------------_----Distance from nearest building-____-_---.-----________- ---------- <br /> El Distance to nearest lot line _.--------------------------------- ---------------------------------------------------------------------------- ---------------- <br /> Remodeling and/or repairing (describe):------------- <br /> -------- <br /> ---------------------------------•-----•---- -------------- <br /> -------------------------------------------------------------•--------------- ----------------------------------------------------------------------------------------------------------------------------- ------ <br /> ----------------------------- ---------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- --------- <br /> ---- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------ <br /> I <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 anti regulations of the San Joaquin Local Health District. <br /> (Signed)--------------- ---------/_ -------------------------------------( r Contractor) <br /> BY:--------------------------------------------------------------------------- ----- ----------(Title)--- <br /> (Plot plan, showing size of lot, location of system in ion to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------T-i_R�_a--------------------------------------------------------------------- DATE---- ------------------- <br /> --- ---�------------.... <br /> REVIEWED BY---- <br /> ------------------------------------- --------- --------- -----------------------------------__------------------------ DATE-----------_--------BUILDING PERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE----------------------------------- <br /> Alterations and/or recommendations:------------- -- ----- -- ------------- ---------- ----------- ---------------------------------------------------------------------------------------- <br /> ------------------------------------ -------- --------------------- ----------------------------------- -------------------------------- -------------------_--------- ------------------------------------------- <br /> r ion to wells, <br /> ------------------------------------------------------------------ ----------------------------------------------------------- ------------------------------------------------------I-------------- --------- <br /> ------------------------ .......................­------ -------------- ----------------------___----- ---- ------------------------------ ­........ ---- ----------------------­--- <br /> ----------------- ....... -------------- ...... -------- <br /> --------- ---------- <br /> ---- --- - ------------ ------------------- -------- ----------------- -------------------------- <br /> FINAL INSPECTION au___6,;�,;7 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 /> E.H.9 2M 1-67 Vanguard Press <br />