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4-� I� '� (APPLICATION FOR SANITATION PERMIT Permit No. ----_-':_.---U.-- <br /> �SiP � (Complete in Duplicate) Date issued 1�-S_/ 0 <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. 549. �p <br /> JOB ADDRESS AND LOCATION_______ __ __ __Lt________ " <br /> Owner's Name_________ __ <br /> Address------------------------------- <br /> Contractor's Name----- --------------- ---------- ------=-----------------------------------------------------•-- Phone------------•-•------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial [J Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -_j--- Number of bedrooms 1 .. Number of baths __ __. Lot size ---__________________________ <br /> Water Supply: Public system x Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to'a depth of 3 feet: Sand E] 'Gravel El Sandy Loam El Clay Loam E] Clay E] Adobe 0 Hardpan Q <br /> Previous Application Made: Yes F-1NoA New Construction: Yes ❑ No ❑ PHA/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 welt________________Distance from foundation--------------------Material-----------------------.------------- <br /> ------------ <br /> [] No. of compartments--------------------------Size---- =_- ------Liquid deppthh_-•----------- ---------Capacity----------------------- <br /> Disposa/l field: Distance from nearest well____ +. @Distance from foundation____ �/_.'-Distance to nearest lot line--/4 <br /> Ld' v7' <br /> Number of lines-----------------------------------Length of eachline-------------- oftrench-----------------------------____-- .� <br /> Type of filter material--------------------------Depth of filter material-----------------------Total length------------------------------------------ t <br /> Seepag Pit: Distance to nearest well----------------------Distance from fou ation__________________.Distance to nearest lot line----------------- <br /> EY Number of pits___./_____-------Lining material_ Size: Diameter_____^-3__`__.__--.Depth-, _J�7...........- <br /> c <br /> Cesspool; Distance from nearest well------------------Distance from foundation:-------------------Lining material---___,_------------------------_____. <br /> "4 Size: Diameter-----i--------------------------------De th---------------------------------------------------Liquid Capacity gals. CA <br /> Privy: Distace from nearest well---------------------------------------------------Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------------------- �+ <br /> Remodeling and/or repairing (describe)=---------------------------------------t----------------------------------------------------•-------------------I——-------------•---- <br /> I <br /> -----------------------------------------------------------------------------------------------------------------------=---•--•--------------------------- 1" <br /> } <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 thed'San Joaquin Local Health District. <br /> (Signed).-", <br /> � -----------------� -- :-2--- .------------------------------------------------------------------------------(Owner and/or Contractor] i <br /> By:---------------------------------------------------- 4 `-----------------------------------------------------(Title]----- ------- ---------------------------- <br /> (Plot plan, showing size of lot,location of system in relation to wells, buildings, etc., can be placed on reverse side). �II <br /> ! I <br /> ( FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED _--------- ------------------- DATE------ ----I- -`-6- ---------------------- I <br /> ---------------------------------- <br /> REVIEWEDBY----------------------------------------------------------------------------=------ ---------------------------------------- DATE----------------• -•--------------------••----------•------- i <br /> BUILDING PERMIT ISSUED----------•---- ------------------------J <br /> DATE <br /> : L DAT,..----------------------------------- <br /> Alterations <br /> and or recommendations.-!-------- __ J -_ <br /> - ? --------------------- ---- •------ <br /> ----------------------------------------------------------------------------- --------------------------------------------------------------------------------- <br /> --- <br /> ----- <br /> --------------------------------------------------------------------------- - <br /> FINAL INSPECTION BY:---- --- - --------- ---------------------------- Date------ -- �-A --- --------------------------------------------- <br /> SAN <br /> ---------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California *Tracy, California <br /> c <br /> ES-4-2M • Revises 1-57 F.P.Co. i <br />