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FOR OFFICE USE: <br /> -------------------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. ....� .� <br /> -------------------------- (Complete-in Duplicate) QQ <br /> - ---- - --- ---- � ------------ -- This Permit Expires 1 Year From Date Issued <br /> Date Issued _/y/T____- <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 Ordi ante No. 549. <br /> JOB ADDRESS AND LOC T N._____.__l ;S' /�o-: <br /> Z---------------- --------------------------------------------------------------------------------------------- <br /> Owner's Name-- `---•----------•-- ------------------------------------ Phone_"-77=3� -_4r__� <br /> Address-------------------�0) /, <br /> - l.i/_ <br /> - - - --- - - -- - <br /> ------------------ ------------------------------------------------------ <br /> - - ----- --- - -------- ------------------- <br /> Contractor's Name 7 -- ------------------------------ Phone.......---------------------------- <br /> Installation will serve: Residence F!f' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __ /___ Number of bedrooms -2 Number of baths.____ Lot size _____ ___ ___ _ ________ _________ <br /> ----------------------- <br /> Water Supply: Public system ®' Community system ❑ Private ❑ Depth to Water Table L.O ft <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: (If yes,date-----___-- ----- ) No Rf New Construction: Yes ❑ No ga" FHA/VA: Yes ❑ No [1}f <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (Nonseptic tank or cesspool permitted if public sewer is available within 200 feet.) \ <br /> Septic Ta/r" Distance from nearest well-----------------Distance from foundation-------------------.Material -----------------.--------------------- `� <br /> No. of compartments - ---Size--------•----------- -----Liquid depth--------- ------- ------- Capacity--• �1 <br /> -- <br /> Disposal Fi I Distance from nearest well --:--........Distance from foundati n__lD___`._.___._.Distance to nearest lot line--- <br /> Number of lines----- _,r__ ___.__Length of each line_ ___-_______-_-Width of french._- � <br /> Type of filter mate rial.__/. _�--.-_-Depth of filter material_/r_`__.--------Total length___­%_�Q___�____._.______.._------- <br /> Seepage Pit: Distance to nearest well- _-----------Distance from foundation`Q__f-____-____-.Distance to nearest lot line_�./____._ <br /> Number of pits__ 1-_______.___Lining material__`lC�o_C._ - Size: Diameter_c '� r_-Depth_____= <br /> Cesspool: Distance from nearest well -------------..-Distance from foundation- ------------___ __Lining material__.___.__.__.________________.__. <br /> ❑ <br /> Size: Diameter. ------ ----- ----------------Depth - .---- ----------------------------Liquid Capacity----------------------------gals <br /> - <br /> Privy: Distance from nearest well_ <br /> -- --- -- ------ ----- -- ---- Distance from nearest building-- --- --------------------------------- <br /> ❑ Distance to nearest lot line-. -- - - <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 ws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed <br /> - ------------------ ------------ ----------------------------------------------- -------- -----(Owner and/or Contractor) <br /> By:. Title _ __ _ __ <br /> ----- --------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> O P RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_----------- .__ _' _ � c--- - DATE------- <br /> ---- �'� <br /> REVIEWED BY---------------------------------- -- ------------------------------ <br /> - -- -- - ------------------ DATE---------------- �-�-------------------- <br /> --------------------------------------------- <br /> -- - ---- --- <br /> BUILDING PERMIT ISSUED-------- --- - DATE <br /> ----------- ---------------- <br /> Alterations and/or recommendations:_.__.________- <br /> ---------I-------------------------------- ---------------- ------ ---------- ---------------- <br /> ---------•------- <br /> FINAL INSPECTION BY: ....................... Date 1--- =� "- <br /> ---------------------------------- <br /> ,/ A JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street <br /> 205 West 9th Street <br /> Stockton,California Lodi California Manteca,California <br /> Tracy,California <br /> E.H.9 2M 1-67 Vanguard Press <br />