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FOR OFFICE USE: - <br /> 4 <br /> --=G---------------- ,.3---- <br /> .._ ... .___..__--------- -------- ------------------- APPLICATION FOR SANITATION PERMIT Permit No. <br /> ---------------`-------------- ---- ------- --------- (Complete•in Duplicate) <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 /> I <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND L CATION______ ___��_._ _____ �;•� _ _ <br /> r <br /> Owner's Name----------- ------ ------------------------------------- --- ------------------ -------- -- ------------ Phone.4)___S_0 <br /> Address..- -,---------------------------- -------------•------- <br /> a. ; <br /> Contractor's Name__ -- -------------- ----------------------- Phon4/0L--� __. <br /> Installation will serve: Residence [] Apartment House ❑ Commercial ❑ Trailer Court 0 ' Motel ❑ Other E]- <br /> Number of living units: j--- Number of bedrooms .a2,Number of baths__ _- Lot size <br /> Water Supply:` Public systemorrlmunity system ❑ Private ❑ Depth to Water Table ------ - ft <br /> C,h�aract of sail o"a depth of4feet• Sand E] Gravel E] Sandy Loam E] Clay Loam 0 Clay El Adobe (Hardpan I-]`--• rP evious APPlic,ation Made (If yes,da#e__ _---� No <br /> [}''-,New Construction: Yes ❑ No 0— FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION.,AND VECIFICATIONS: <br /> (No septic-tank or'cesspool permitted if public sewer-is available within 200 feet.) <br /> Septic Tank: Distance from nearest well------------------Distance from foundation-------------------Material <br /> ❑ No. of compartments`` ........Size----------_---------- Liquid de th___..___- ------ ........Capacity <br /> Disposal Field: Distance from earesfi well" �..-_-Distance from foundation_._f(]:•_.....Distance to nearest lot <br /> Number of lines__________ - <br /> -------- <br /> Length of each line-------- (� ------------Width of trench--_.L` <br /> ---- ---- - <br /> Type of filter material ga—Depth of filter material..../�.'�___._...Total length_____-;?_�Q_ _____________________ <br /> Seepage Pit: Distance to nearest well--------------------___Distance from foundation-------------------.Distance to nearest lot line---._.________._ <br /> ❑ Number of pits--- ------------------Lining material-------------......... Size: Diameter -------__Depth------------------------.-------- <br /> Cesspool: � Distance from nearest well ______________-Distance from foundation...... _,Lining material--__--------....____.__.____-___...__. <br /> ❑ Size: Diameter- ---------- --------------- Depth---- ---------- ----------- - --- --- ..!------------Liquid Capacity----------------------------gals. r <br /> Privy: Distance from nearest well-----_--------------------------------------_____Distance from nearest building-_-.__ --------------------------- <br /> .___.- <br /> I ❑ <br /> Distance to nearest lot line- ------ ---------- ---- -------------------------------•------------- ---------- - -- ------------------- ---•�----------------- <br /> Remodeling and/or repairing (describe):__.__..__ :- ._ ------e_1.2--_--___ <br /> rc' .- ---------------•--- ---•------•----------------- <br /> 9 ------------------------------------------------ ----------------------------- <br /> ------ - - ----------------- - --------------- --------- <br /> hereby laws, <br /> preparethis application and that the work <br /> State ws, and rules and regulations of the San Joaquin Local H will,be done in accordance with San Joaquin County <br /> ordinances <br /> ealW Dis#riot. <br /> (Signed)-----: ---------------•--- ------ --- -----------------_-(Owner and/or Contractor) <br /> - ------------- - <br /> By � - -- - -- ---- - ----------- ---- �---------------------- -----{Title)._.. -----...---- - --- - - _ �---- ------- <br /> (Plot plan, showing size of lot, loc on of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLYr <br /> APPLICATION ACCEPTEDBY___ <br /> =--- --------------------------- --------------------------------------- DATE---- 1�'"b <br /> _= <br /> REVIEWED BY - - DATE ------- <br /> BUILDING PERMIT ISSUED-------- ----------------------- -- ----------------- ------------- - -------------------------------- DATE - <br /> Alterations and/or recommendations:,------------------------ _._ <br /> ---•--------- --- - - - ----------- ----------Z--------------- ----- <br /> ------ -. ---- ---------------------------- --- --------------------------- --------------------------------------- --------•---- ------ .-.._..-------- --------- --------- <br /> ----------------- ------ ----- -------- --- -•------ --------------- ------- - - --- --- <br /> - -- <br /> - ----- -- -------------- -------- - - - -- - <br /> --------------------------------------------- -------=------------------------------------------------------- <br /> FINAL INSPECTION BY:.... q ---------- ------------------- Date. 1 L ........ ---------------•------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1401 E.Naselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi, California Manteca,California Tracy,California <br /> E.H.9 2M 1-67 Vanguard press <br />