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FOR OFFICE USE: <br /> ------- ------ ------ <br /> Permit No. <br /> -------- -----------r.11----------- --------- APPLICATION FOR'SAINITATION PERMIT <br /> ---------- <br /> ------------ <br /> -- ------------- --------------------------- ----------- (Complete in Duplicate) '�Dafe 1,%ued <br />- <br /> ------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the workherein described. <br /> This application is made in compliance with County Ordinance No.,549. <br /> JOB ADDRESS AN LOCATi0 ..... ✓--- -- --- <br /> .......... <br /> j --- -------------------------------- <br /> Owner's Name ---------------------------------------------- ------------------------ <br /> 0 <br /> ------- Phone------------ ------------------ <br /> ---------- - <br /> Address------------------ ......e­ ------------------------ ---------------------------------------------- <br /> Contractor's Name--- ...... - ------------------------------------------------------------------------------ Phone----------------------------------- <br /> -installation will serve: Residence ??"Apartment House El Commercial Ej Trailer Court ❑ Motel Ej Other [I <br /> Number of living units: ___/_ Number of bedrooms _X_ Number of baths _/--- Lot size 49--------------------------- <br /> vvater Supply: Public system 931"Community system El Private E] Depth to Wafer Table <br /> Character of soil to a depth of 3 feet: Sand E] Gravel Fj Sandy Loam El Clay Loam [] Clay ❑ Adobe IZA,`nardpan <br /> ❑ <br /> Previous Application Made: (If yes,date__--.___..-,__.._ .) No �New Construction: Yes 0 No g?­ FHA/VA-. Yes E No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic�ank:, Distance from nearest well_._.________----Distance from foundation--------------------Material------------------------------------------------- <br /> "i5)ZlIq No. of compartments-------------------- -----Size-----_----------------- -------Liquid.clepth---- -------------- -----Qaocity------------------r_ <br /> Disposal Field: Distance from nearest well-_---- -----Distance from foundation__��w____-O'__Disiance to nearest lot line---4--------- <br /> Number of lines--------/...... &p__ Width of trench__'_X.---__-____________________" <br /> --------- Length of each line__-_ <br /> Type of filter materiavel-64i'4 Depth of filter mater�al----Zop-­1----Total length__21-,�1&------------------------------ <br /> Seepage Pit: Distance to nearest well-----2!r?rn----------Distance f.rQm foundation__ Distance to nearest lot line_.415;__,�------- Q <br /> Number of pits-----/-------------Lining material-- 97, _Size: D!amefer___S__.Fw <br /> Cesspool: Distance from nearest well________________ Distance from foundation.-.._.._*.. _._...Lining material_---_._____---_____._-_--___..____ <br /> ❑ Size: <br /> aterial-------------- ----------------------Size: Diameter------_---------- ------------------Depf h------------------------------------ -----------Liquid Capacity- -------------------------gals. <br /> Privy-.- Disfarce from nearest well----------------------------------------- ------Distance rom nearest building------------------------------------------ <br /> Distanceto nearest lot line-- ---------- ----------------------- ----------------------------------I----------------------------------- <br /> Remodeling and/or repairing (describe):__-__.._. ---------- -------------------------------------------------------- <br /> ------------------------------------------------------------------------------------ -------------------------------------- ------------- ------------------------------------------------------------------- -- <br /> . I . 4 f <br /> - --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- <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 f�e San Joaquin Lo al Health Dis+rici. <br /> �a Contractor) <br /> - --- ------- -------------------- -(Signed)-------------------------------------------------------�;9,4o - --------- - aid <br /> By:----------------------------------------------- ---------------------------------- <br /> 44, --- ----------(Title)--- -------- ---- --- -------------- <br /> (Plot plan, showing size of lot, location'of'system in rel to �mells, buildings, etc., can be placed on reverse side). <br /> on �,e� <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------- 6 -- -------I------------------------------------------ DATE----- <br /> REVIEWED <br /> ATE-----REVIEWED BY------------------------------- --------- --- --------------- ---------------------------- ---------------------------------- DATE---- ---------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------- ----------------------------------------------------------------- ------ DATE----- ------------------------------------------------------ <br /> Alterationsand/or recommendations:------------------------- -- ------------------- ------------------------- ------------------------ ----------•---------------------------------------------- <br /> ------------------------------------ -- --------------------------------- ------------ ------------------------------------------------------------------------------------------------------------------------------------- <br /> - ------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------- -------------------- ----------------------------------------------------------------------- ------------------------------------------------------------------- ------------- ------- <br /> --------------- ----------------- ---- --------------------------------- <br /> -------------------- ---­....... -------------------------------------- ---------------- ------------- --------------------- ------- --------- <br /> FINAL INSPECTION Date.... f --------------- <br /> ------------- ------------- ------- .......I- ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 ,,1ox*l,on A,,*. 3o0 vL,,Oak Street 124 sycamore Street 205 West 9,h I'-"'e, <br /> Stocklan,California Lodi,California Manteca,California Tracy,California <br />