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APPLICATION FOR SANITATION PERMIT Permit No, Aa__2�.7--- <br /> (Complete in Duplicate) 3 <br /> _11r7 <br /> 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 <br /> application is made in complia.nce with County Or14`nance No. 549. <br /> JOB ADDRESS AND <br /> ------------------------------------------------------------- --------------------------- <br /> Owner's Name-------- -------- --------------------------------------------------------------------------- Phone_ <br /> Address-------------------------------------------------- <br /> Contractor's Name---------------------------- --- -------------------------------------------------------------- =------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence Apartment House E] Commercial [-] Trailer Court E] Motel ❑ Other El <br /> Number of living units: -14umber of bedroorns3----- Number of baths J'____ Lot size 01 <br /> ----------------------- <br /> Water Supply: Public system L Community system - Private E] Depth to Water Table -------- ff. <br /> Hardpan E] <br /> Ha <br /> Character of soil to a depth of 3 feet: Sand [],.,Gravel E] Sandy Loam [] Clay Loam El Clay E] Adobe 2___< <br /> Previous Application Made: Yes E] No New Construction:, VNo Ej PHA/VA. Yes D No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: I . . <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> Septic nk. Distance from nearest well-- _-Distance from"A :1 <br /> ---------- foundat�on----I ----------Mat, <br /> No, of comparimenfs---- ---- -------- ------ --- <br /> -Liquid depth--------q - ------ <br /> .......... y---- <br /> ......capacit -- <br /> I - <br /> Disposal Field: Distance from nearest wDistance from foundation__10�__Distance to nearest lot lin <br /> Number of lines----------%__ ------------------Length of each line------------------------------Width of trench---------------------- ------------ <br /> Type of filter maferial-------------------------Depth of filter material-----------------------Total length___._______----__________---____________-- <br /> Seepage <br /> ength------------------------------------------ <br /> Seepage Pit: Distance to nearest well-------------------:--Distance from foundation--------------------Distance to nearest lot line_________________ <br /> ❑ <br /> ine----------------- <br /> 1771 Number of pifs!---------------------Lining material-----------------------S;ze: Diameter------_----------------Depth----------___------------------- <br /> Cesspool: <br /> epth--------------------------------- <br /> Cesspool: Distance from nearest _Z711f,ance from fo-un,da-tion-------------------- Lining material-_----___.__._.__________________ <br /> ❑ <br /> aterial-- ---------------------------------- <br /> El Size: Diameter-I----------------------- -----------Depth----------------------------- ----------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance fromlnearest well ___..______________________________________Distance from nearest building__________.__ __ _____________________._. <br /> ❑ <br /> uilding--------------------------------------- <br /> Ell Distance to nearest lot line_.____._.____________.________ "`��� <br /> Remodeling <br /> ine--------------------------------- -Remodeling and/or repairing (describe)------------------------------------------- ------------------------------------------------------------------------------------------------------------- <br /> ------------ -- ----------------- <br /> -------­--------------------- ----------------------------------------------------- —--------------------------------------------------------------------- <br /> -------------------------------------------------- <br /> L -------------------------------------------------------- ----------------- ---------------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I have pre'pared this application and that +he work will be done in accordance with San Joaquin CcLrnij' <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)-,---- -- --- ...2- <br /> ------------------- ----------------------------------------------------------------------------------------(Owner and/or Contractor) <br /> By---------------;--------------------------I----------------------------------------------------------------------------------------(Tifle)--------------------------------------------- - --------------- <br /> (Plot plan, showing size of lot, location of system in.relafion to wells, buildings, etc., can be placed on reverse side). <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----= ------------ -- -------------------------------------------------------------- DATE--------------------- "��� <br /> t � <br /> REVIEWED <br /> ATE---------------------- <br /> REVIEWED BY-------- 11 <br /> -------------------------------- - -- ---- ---------------------------------------------------------------- DATE------ <br /> BUILDING PERMIT ISSUED-------------- <br /> ------------------------------------------------------------ DATE-- -- - -- ---------------------------------------------- <br /> Alterations and/or recommendations- - -------------- ------------------- ------ -----------------------------------------------I— -J_ <br /> ---------------­-------__--------------------------- <br /> --------------------------------------------------- -----------V-------------------------------------------------------------------------- ------------------------------------------------------------------ <br /> --------------I------------------I---------------------------I <br /> :-------^-------------------------------------------------------*-------------------------------------------------------------------------------------------- <br /> ----------- -------------------------------------- ------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:--- Date----------I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street �kk300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California 1 Lodi, California Manteca, California Tracy, California <br /> E5-9-2M � Revises 1.57 F.P.CO- <br />