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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT Permit No. . <br /> ._Q r <br /> .-- _, (Complete in Duplicate) <br /> -�-�� �- Date Issued"--7.�1�-�-- <br /> .......... - --_--------------------------_..___.._ Thts irmit 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 /> JOBADDRESS AND ATIO ------- I ----------- --------------------------------------------------- ---------------------­-------------- <br /> Owner's Name--- - -- - ---- --------------- --- Phone-----------------------r <br /> Address--- �.... ...... ------- --{rd{F�------- ------ <br /> Contractor's Name--- ------------------ -� �� - ----------------------------•--------------- ------ Phone----------------------------------- <br /> Installation will serve- Residence Q,Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _/--- Number of bedrooms _ _ Number of baths _/._ Lot size .fQQx--P-Q.`--------------------------- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to WateC,Table 16�7ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ElClay Loam E] -Clay E] Adobe ardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No J2,' New Construction: Yes ❑ No g4-FHA/VA: Yes ❑ NoZ�_ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: i <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ; <br /> ti <br /> Septic Tank- Distance from nearest well_________________Distance from foundation--------------------Material--- -_- <br /> 'z____.....___________._.___._.... <br /> 1 � No. of compartments-------------------- Size--•------------------------- ---Liquid depth-------------------..:_--Capacity----------------------- <br /> Dial Field'- Disfance from nearest well....-�_____Distance from foundation_ . Q.*�.-.-.Distance to nearest log line_ ----------- <br /> 5)0!1 <br /> Number of lines-------/-______ _ ___ _ ____Length of each line_-_ '� Width of trench.�-------------.-------__.____ <br /> Type of filter material./__1�_,�i0j_�e Depth of filter material----,`,____...... otal length-----/t___-...__-_-_____________ <br /> Seepage Pit: Distance to nearest well------- <br /> ------Distance from foundation__Za__!�--- Distance to nearest lot <br /> Number of pits---- -------------Lining materialSize: Diamete r__,61'�...._.-__. <br /> F, <br /> Cesspool: Distance from nearest well-----------------Distance from foundation....----------------Lining material__._________..____-_--_____--....:` <br /> ❑ Size: Diameter-------------------------- ------- -- Depth.------------------------------------------ ------Liquid Capacity....--- --------- ----gals. <br /> h Privy: Distance from nearest well------------_____________._____-.---_-------._Distance from nearest building--------------------- <br /> ----------------------- <br /> Distance <br /> ._-_-_'_______Y__:_:__:_._______._ _Distance to nearest lot line-------------------------- -------------------------­---I----------------------------------- - ----------------_---------- <br /> + S <br /> Remodeling and/or repairing (describe}:_...----- 1 + f/d P.�.�---------------------- <br /> - -------------- <br /> ---------------------------- ---------------- --------------•------------------------------------------ --- - ------------------ -- <br /> --- <br /> -------- <br /> r <br /> ------------------------------------ -----------------------------------------------------------------------•-------------------------------------------- I <br /> I here6y 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 /> (Signed) -� �/� .-.---_--- -( or Contracto>) <br /> ,-- <br /> - --- --- <br /> " $y:---------------------•--------------------------------------------------- ---------------------(Title)- _------- <br /> (Plot plan, showing size of lot, location of system in tion to wells, but dings, etc., can be placed on reverse side). <br />' OR DEPARTMENT USE ONLY - <br /> APPLICATION ACCEPTED BY ------------------------------------ DATE- ----- -------------- <br /> REVIEWEDBY------------------------------- -- ------ -----------------------:---------------------------------------------- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED----------------------------------- --------------------------------------------------- ---- - DATE------------------------------------------------------------- <br /> Alterations and/or recommendations:---------- ------- ----------------------•---------- ---- -------------------------------------- -- ----------- <br /> -•-------- - ------------•-------- -- ----------------------------------------------- ------------------- -------------------------------------•----- --•--•---------------------------- <br /> ------------------------------------------------------- -----•------------------------------------- ------------ ------------_--------__--------- ------------------------- i <br /> ------------------------------------ -• --------- .... -------------------------------------------------------------- ----------------------------------- ------ ---------- -- ------ ---- <br /> ---------------- -------------------------------------------------------------- -- -------------------------------------- --------------------------------------------------------- y <br /> F 1 <br /> FINAL INSPECTION BY:_----------- ` � Date--..-- 7 ��� � � ------------------------- s <br /> � . ._ _ . , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 9 <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California _ Mantecar California Tracy,California <br />