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FOR OFFI USE- f <br /> APPLICATION FOR SANITATION PERMIT Permit No. ./ � .. <br /> --------------------- <br /> ------------------- <br /> (Complete In Duplicate) <br /> V+ Date Issued ..,-... <br /> --- --- ------- ----- _---__-____--.------------_ This Permit Expires 1 Year From Date Issued <br /> �pplica#ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> .-chis application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION-__3_4 -----•-•- - ----------•--------- <br /> - Phone. �... _ _ S' <br /> Owner's Name----- R 1�4 - '------- I-�----•- ----- . .. <br /> Address--------------- -•-•--------------------------•- --------------------•-- -----------------------------------------•------------------ -----------------•---------------------------- <br /> Contractor's Name-- N - --- ,`i ¢^ � � , � "` ,= Phone..,.. --.�-�:. <br /> Installation will serve: Residence [Apartment House ❑ Commercial/❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _1.--- Number of bedrooms _- -. Number of baths _-!.--- Lot size 0_f- --1 SQ F <br /> Water Supply: Public system 2—Community system ❑ Private ❑ Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ja`�Hardpan ❑ <br /> Previous Application Made: (if yes,date---------------------) No 52"�New Construction: Yes E�'�o ❑ FHA/VA: Yes E] No R' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet..) _ <br /> Septic Ta k: Distance from nearest well----_----_------Distance from foundation__-_-....__----.--Material------------------------------------------------- <br /> No. of compartments:--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- i <br /> isposal Field: Distance from nearest well...- .-.-----Distance from foundation--------------------Distance to nearest lot line-------------- <br /> Number of lines-----------------------------------Length of each line----------------------------.Width of trench-------.----_,-----------------.--- <br /> a <br /> Type of filter material------------------_-----Depth of filter material---------.-------------Total length-.__-__----__---_--------_--�-`_-_--- <br /> Seepage Pit: Distance to nearest well .______--__Distance r�o�m� ggfoundation--_�_ ...__-_._-.Distan�e to nearest t e,. ..-..... <br /> . <br /> Number of pits-_A---------------Lining material---ft�:4✓ _. Size. Diameter-__ <br /> 3-3----- -----.Depth----•--•---- ?n_*z(,,.� -, <br /> es❑spool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------..---.__-----..-------_---..-.-. <br /> , - • als.Size: Diameter Depth ------- Li uid Ca acitY----------_--------- - 9 Q <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------.._-----_-_-----.-------... <br /> ❑ Distance to nearest lot line---------------------- ---------------------- -------------------_--- -----------••------------------------------------------------------- <br /> Remodeling and/or repairing (describe):--___- " --.--�! L)y _.._dib----k_ --- ! <br /> _---------------- -- <br /> ------------------------------------- --- •------•-----...-------••-----•-•------------------...--------------•--------------------------------------•------------------------------------ ------ <br /> I 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 reguI flons of the San Joaquin Local Health District. <br /> p _-_---_--------------------- Owner and/or Contractor <br /> (Signed)------ -------- - ---- Gy r { / I <br /> S <br /> --- <br /> By: = - -- � ¢''�-� ------- --------------------•--------- ITit1e) <br /> 3LN-�------ - -•f- --- ------ <br /> (Plot plan, showing size lot, location of system in relation to wells, buildings, etc., can be placed on reverse si e). J,7- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY---- -.-.---------- --- --------------•---------- -------------- DATE---- --------- --------------------------------- <br /> REVIEWED <br /> ----------------------------- <br /> REVIEWEDBY-------------------------;------------------- -----------------------------------•------------------------------------•--- DATE---------_------ •---------------------------------------- <br /> BUILDING PERMIT ISSUED----------------------------------------------- ----------------------------------------------------- DATE.-----------------•--------------------------------------- <br /> -- <br /> IAlterations and/or recommendations------- ------------------------------------------------------------------------_--------------------------------------------------------------------------- <br /> -------------•-• --------------------------------------- ------------------------__ . <br /> FINAL INSPECTION BY: Date...I------ .. -��----------•----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California monteca,California Tracy,California <br /> E5.9 REVISED 0.59 F.P.00.ZM 6.60 <br /> 1 <br />