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FOR OFFICE USE: <br /> ----- ---------- ----- - ---------- - ---------------- <br /> __ ______ __ ____ ___ ___ ____ _ APPLICATION FOR SANITATION PERMIT Permit No. .:..� �� <br /> .........I——...........M....----------- ---- ------ (Complete-in Duplicate) <br /> _ __._.._ _. <br /> .__.-.._. .______-__.__._.___._.__ _ <br /> .-.. . This Permit Expires 1 Year From Date Issued 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. 549. /� .bi/• .,,_ <br /> JOB ADDRESS AND LOCATION / JI4�lL- - .iC�/> -l.�f <br /> Owner's Name &A4--- -- ---------- ---•-- Phone--------------- --------- -------- <br /> Address-------- <br /> -------Address-------- i ------------ <br /> --------------- - / ` <br /> Contractor's Name` C4iC" ----- � -- --- ------ ----------------------------------- ---- Phone-- U�r_ 0 <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer' Motel ❑ Other ❑ <br /> Number of living units: ..... Number of bedrooms ..Number of baths._/__. Lot size _----------------\ <br /> Water Supply: Public system ❑ Community system ❑ Private 01 Depth to Water Table ft \ <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: (If yes,date---------- ...... ) No ❑ New Construction: Yes ❑ No*_ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: v\ <br /> (No septic tank or cesspool permitted if public sewer is available within 200 fe��eeqt.), <br /> Septic Tank: Distance from nearest,gwelL� _�Distanr fron�.fo dalton___ 0- ---- Material -. -------------------- <br /> No. of compartments-1..................SizJ_Z_f_ 4 3_-.Liquid depth...-h_-..._ Capacity.s'i9_I�-Q <br /> Disposal Field: Distance from nearest well-/-.SV.-Distance from foundation_ _'_..Distance to nearest lot line._tz;o r <br /> Number of lines ._-...... _...__ _ _Length of each line4?..�_-----._------WidthDepth <br /> length._-. -��-!"------------------------ <br /> SePit: Distance to nearest well...r7__�.k9_'__Distanc from foundation�.�.f...._...Distance to nearest lot line__ <br /> eZ ---------Linin material ----- ��-- -r---De th__t"�-.i--------------------- <br /> dumber of pits_-_ _V--------------- g - _ Size: Diameter.__ - � p <br /> Cesspool: Distance from nearest well ----------------Distance from foundation.....-------.......Lining material...-..-_-.--------..._..---._.-____-_. <br /> E❑ Size: Diameter- -- ------- ---- --- - ----- ----Depth------------------------------------ --------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well...- ----.....................Distance from nearest building----------------------------------------- <br /> 0 Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------- ---------- <br /> Remodeling and/or repairing (describe -------------------- ------ --- - _;-----------•------------------------------------------- -------.....-------------------------------------------- <br /> --•----------------------------------- ---' ----- ! - 1- ----------------------- -- ----------- ------------------ ------------------------------ <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- - - ----- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, S ws, and rules d regulations of the San Joaquin Local Health District. <br /> (Signed) ------- -- - ----- ------------ (4U01111- <br /> By: <br /> Contractor <br /> B :-------------------------------- ---------- --- - Title ------------------ .----- - ------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, 'wilding , etc., can be placed on reverse side). <br /> 17 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---. -------------------------------------------------------- ------ DATE-7 ------- --- - <br /> REVIEWED BY------------------------- -------- - -- --- DATE <br /> -- ------------ ------------------------------ <br /> BUILDINGPERMIT ISSUED-------- -- -- ----------------- ---------------------------------------------------------- ---------- DATE----------------- ----------------------- <br /> Alterations and/or recommendations:---------- --------- . -- ---- - ---- ------------- ------------------------------- ------------------ ----------------- <br /> -------------------------------------------------------------------------- ------ --------- ---- -- -------------------------------------- ---------------•--------------------- ------------------------------------ <br /> --------------------•------ ----------------. ------- ----------------- ---------------------------------------- -------------------------------------- -------------------------------------- <br /> ----- -- ---------- --------- ------ --------- ---------- ------------------------------------------------------- ------ -- ------ ------------------------------ ----- <br /> FINAL INSPECTION BY:.----- -- - - ------- - ----------- Date------- --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> 5locklon,California Lodi California Manteca,California Tracy,California <br /> E.H.9 2M 1.67 Vanguard Press S•y.may r r V I(cj <br />