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FOR OFFICE USE: <br /> ----------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. f1KY_. <br /> (Complete in Duplicate) <br /> ..__.___..... . .. ..... This Permit Expires 1 Year From Date Issued Date Issued/__r7_____..._� <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 complianceith County Ordinan e No. 549. <br /> JOB ADDRESS AN LOCATION. <br /> Owner's Name - ---•- ----- ---------- -- ---- ------•---- -----------------•--------- ------------------------------------ Phone-----------••----------------------- <br /> Address--- Zp---0-`r . 4: -- .. s. ----------------- --- ----- ----------------------------------------------•-----------------------------___---- <br /> Contractor's Name--- - -- t- -- ----------------- ---•••--------------•------------------------------------------------ Phone <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other p <br /> Number of living units-. / --____ Number of bedrooms . - Number of baths ---1-- Lot size __ D X-2/p------------------------------ <br /> Water Supply: Public system [+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 23---Nardpan ❑ <br /> i • <br /> Previous Application Made: (If yes,date-----------.........) No [ New Construction: Yes F1 No,ffj-_'7F.HA/VA: Yes ❑ _No �� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS -.,. <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sep ' Tandem Distance from nearest well_________________Distance from foundation <br /> -id de th__Material-== __C-- acit <br /> � 7 No. of compartments-------------------- ----Size-----••------- q P. P y- <br /> Disp I-Field: Distance from nearest well_—_......Distance from foundationlo._�-.-_.-..Distance to nearest lot line_�_-___.._ <br /> Number of lines-----./________ __________________Length of each line__30?.`______----_._.Width of trench.__ .--------------------- <br /> Type <br /> . --_-_-_____-__Type of filter of filter material__l�--------------Total length--_- ---------------------- <br /> Seepage <br /> -----------------See a e Pit: Distance to nearest well-----— "Distance -fmm foun ation_Zv___.-__-_.Distance to nearestIoII ----___-._-_ <br /> pitsc�� <br /> �J Number of .__.L-,_ ___-__-____Lining material__.�__!_4..pSize: Diameter______3�____.___Depth_._....__.------------------------ <br /> Cesspool: <br /> .__________._.'___ __Cesspool: Distance from nearest well----------:___'Distance from foundation----------------.-.Lining material.........--------------------t.:__._--. <br /> ❑ Size: Diameter-----=-------------------------- Depth- ------------------------------------------s-----Liquid Capacity_...___------------------gals, <br /> Privy: Distance to nearest lot linle---------------------------------- ----------------------------------Distance from:neares- buildin------ ---------------------- ----------- <br /> g------------ r <br /> Remodeling and/'or repairing (describe) ---------- • -----•--• ---•-----------------•-•---------•-- ------•----- <br /> ------------•-----••----------= = -------------------------- ------------------------­---------------------------------------------------------- ------•--------------------------•-------------------------------- <br /> ------------------ <br /> --•----•----------------------- <br /> ---------------------------------------------------,___-_____I_________--____-___.•____._______-__--.__-___________-__-_-___._._--.--__-_-__-_-_--_-_-_____----_-_-___-____.--_--___-___________.----_____-_.-.-_--_.-------- <br /> I hereby certify that 1 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 /> k <br /> (Signed)----------------------------------- --- --- - ------------ <br /> - -: - - -- ------ ------------------------------------ -------------- <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 /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- __ ' _ (� _- <br /> ------------------ -- ---------------------------------------- DATE--- -_fes------ -"�- - <br /> _____________________ <br /> REVIEWEDBY--------------------------------- ---- - ----------------------------------------------------------------------------- DATE---------------------------- <br /> BUILDING PERMIT ISSUED =---` --------- - - DATE.- --- <br /> ------------------------- <br /> ----------- <br /> Alteraiions and/or recommendations:_..a?.S__.1�` _ F'.�/ __----- - ------------- <br /> l49f^ <br /> -------------------------------------------------•-- ---------- •---------------------------------------- <br /> FINAL INSPECTION BY:........... ----- Date._....._f6-------- 3---/ (----r <br /> SAN JOAQUIN LOCALHEALTHDISTRICT <br /> 1601 E.Haxellon Ave. 300 West Oak Street , 124 Sycamore Street 205 West 9th Street t <br /> Stockton,California Lodi,California 4 Manteca,California Tracy,California <br /> i <br /> • I <br />