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OFFI E E: <br /> Ll <br /> ______________________________________ \ APPLICATION FOR SANITATION PERMIT Permit No. ..1.3 <br /> -------------------------- (Complete in Duplicate) <br /> ------------------------- This Permit Expires 1 Year From Date Issued Date Issued ---:�o................ <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 , rdinan a No. 549. <br /> JOBADDRESS AND LOCA I N /"� ---------------------------------•--------••---------......-----•--------........_...........--•...... <br /> Owner's Name------------- •---------...:_ � --------------•--•--- Phone.................................... <br /> Address----- ••-•-- J ... ._. _ -� <br /> Contractors Name........ <br /> .....................[l:,-----i ---------......................................... Phone................................... <br /> Installation will serve: Residence [Apartment House E] Commercial ❑ Trailer Court ❑�,�Motel [3Other E]Number of living units: ._j.._. Number of bedrooms _.3.. Number of baths ----f__ Lot size .. _ .d........................... <br /> Water Supply: Public system [2 Community system ❑ Private a-Depth to Water Table AP_ ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel F] Sandy Loam C] Clay Loam ❑ Clay [I Adobe�ardpan❑ <br /> Previous Application Made: (If yes,date--------------------) No [3 New Construction: Yes E] No ❑ 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 /> SApti ank: Distance from nearest well.................Distance from foundation....................Material_ __.._..._ ,...............:...:...... <br /> No. of compartments--------------------------Size................................Liquid depth------------------------..Capacity....................... <br /> Dis Distance from nearest//well_w`a_____._Distance from foundation.....'`.............Distance to nearest lot line....a�........ <br /> Number of lines----•----f------------------------Length of each line.......$.Q-----------------Width of trench�.F0. ... <br /> Type of filter material...�_C_k---------Depth of filter material_.__lff --------Total length......Q.!G__........::............... <br /> See e` ' Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot hne <br /> Number of pits______________________Lining material.......................Size: Diameter.......................Depth ._....... _.._.... <br /> .. <br /> spool: Distance from nearest well................Distance from foundation--.................Lining materiel.._ ...... <br /> °•� Size: Diamater--------------------------------------Depth----------------------------------------------------Liquid Capacity. gals lit <br /> Privy: Distance from nearest well-----------------------------------------------.-Distance from nearest building............. \ <br /> ❑ Distance to nearest lot line-------------•------•--------- •---._..----- •-•--------------------------------- ----• ......... .....:. ....._:: ..,._. <br /> Remodeling and/or repairing (describe):------------------------ --•------- ----••---------------•--••------••-••••--------••------•-------•-••----- _ <br /> ------------------------ -----•------•----------- •-•••----------•----------•-------•----•----•--••••-•-•-------•--------•---••--------•---------•-•--•-----------•-••------••--•••...---•••_--•- -•---•--•-•_._.. <br /> I hereby certify that I have prepared this a plication and that the work will be done in accordance with San Joaquin County f- <br /> ordinances, State laws, and rules and reg a sof the San Joaquin Local Health District. <br /> (Signed).....................................---••----•----- ------ --- ------- ----- ................................................. ....... ..............(Owner and/or Contractor) <br /> By:.----------•........................ •------------------------•--.........................................................(riifle)-------------------------------------------------------- --- <br /> (Plot plan, showing size of lot, location o system in lation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- `z�' z DATE 2 /. . ...'467 <br /> REVIEWED BY..................................... DATE---------•--------•---•-----------..-•---•--•---•-------- <br /> f------------------------------------- --------------------------- <br /> BUILDINGPERMIT ISSUED..............................................................—...................................... DATE............................................................. <br /> Alterations and/or recommendations------------------------------- ---------------------------------------•-----------•---•-••-----•-•----------.......---•------••----••--------•--•----•-......-- <br /> ---•--••-•-----•.................•-------•---..._......---------- .....................................---------------•-------------••••--------••-•--------••••••----•-••-----•••----•-••----•--.....-•---.._....------ <br /> ........................................•----•-•------••-•-----------------•----••-----•-----------------------------•-•--•-•----••-•---••••----•••--•-----------•---•-------•---•--•-----.................................. <br /> --•-•-••-•--••--•-•--••-----•---•-•---------•.....................---------------••---•----------------------••--••----•-------•--- --•----------•-••----•----•-•••-•••-----•----------••---•--•----••--•--....-••---•------- <br /> •-••--•••••................................ . ........ --- -----------•-----•--------------------------------------------------------------------------------- ----- <br /> 1 l <br /> FINAL INSPECTION BY:---- r Date.... 1 ... G <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,Californlet Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 5-89 ;M 5-61�AYLAS <br />