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iFOR OFFICE�USE: <br /> -3---- Permit No. <br /> --------------------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) Date Issued <br /> --------- ------------------------------- <br /> t This Permit 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, 544. <br /> JOB ADDRESS AND LO ATIO .. >' v� � <br /> • Phone-----------•-----------•-------_---- <br /> Owner's Name_ -- ------------------------------------------ <br /> -� ?t� .---------- <br /> Address__s- ---------- ----------------------- <br /> -----•-----------------•---------------. -------------------------------•-----•----------- <br /> 1 ---------------- <br /> •Contractor's Name- ----- -----------------------------------------------------------------------------•--------------- Phone� <br /> Onstallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> F <br /> o <br /> Number of living units: _/__--Number of bedrooms __/_ Number of baths _1---- Lot size mg-�-- - ----� <br /> Y.. e . l � <br /> + Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table aft_ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel F1 Sandy Loam E] Clay Loam El Clay E] Adobe Hardpan C1 <br /> Previous Application Made: (If yes date--------------------) No Rr-INew Construction: Yes ❑ No ® FHA/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 /> Septic Tank:/, Distance from nearest well-_-t-------------Distance from foundation------------------- Material- <br /> No. of compartments----------------------- -Size--------------------------------Liquid depth------------ ----------- Capacity... <br /> Disposal FieldC.;' � Distance from nearest well___'-.""_.-._.Distance from foundatio�_ -�--_-.Distance to nearest lot line. <br /> � <br /> Number of lines-------- ___ Length of each line-_�__l------ I/__._.Width of trench. _ _r_____________________ <br /> I4 Type of filter material r�. eDepth of filter material__,.----.--Total length___------------- ------ q <br /> Seepage Pit: Distance to neares+,well--------------.-------Distance from foundation_-__-___--_____-_-.Distance to nearest lot line-- -------------. <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------- ----Depth-- ----------------------------- \Q <br /> ­" V <br /> Cesspool: Distance frominearest well-----------------Distance from foundation._-__._._-_..______.Lining material_..____-___..______-___.______als. <br /> ❑ .Depth------------------------------------------------- Liquid Capacity g <br /> Size: Qiameter------------------�---- ------ ----- <br /> {{ __.Distance from nearest building <br /> ( Privy: Distance from knearest well ------------ - -------------------------- ---------- -------------- ----------- <br /> ❑ Distance to nearest lot line <br /> ----------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe)---------- ------ <br /> --------------------------------------------------------- <br /> ---- , <br /> ------------------------­- ------------- <br /> 1 ----------------------------------------------------- <br /> ----- ------- ------------- -- -------------------------=------------------------------------------------------------------------------ -----••--------------------------------------------------------------------- <br /> j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> f ordinances, State laws, and rules �reulatfions of the San Joaquin Local Health District. <br /> Ct <br /> ------ -------- ------ --------------- <br /> (Signed)_ r <br /> ont <br /> o roc or) <br /> ' (Title)... <br /> ------- <br /> r - <br /> (Plot plan, showing size of lot, location of system in relatio wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> ---------------- <br /> APPLICATION ACCEPTED BY- -------------------------------------- DATE--------- -------- <br /> ( REVIEWED BY---- --------------------------- ---------------------------------------------------------------------------------------- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED-------------- ------• ------------------------------------ DATE----------------------------- ------------ --'--------------- <br /> Alterations and/or recommendations- --------------------- ---------------------------------------------------------- <br /> t ---------------------- ---------------------------------------------- <br /> ----------- <br /> ------ ---------------- <br /> ---------------------------------- ------------- <br /> --------------------------------------------------------- <br /> ----------------------------------------------- <br /> t1 ------- -------------------- ---------------- ---- <br /> FINAL INSPECTION BY:-------'...._ ----------------- - <br /> Date- l-2 r/�.�. 3. ------ <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I r <br /> 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,"California i }' Manteca,California Tracy,California <br /> r <br /> F.P.CC. <br />