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FOR OFFICE USE: <br /> ----- ---------------------------------- - - <br /> --------------------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. ---/..._, a� <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 /> This application is made in compliance with County Ordinance No. 549.&'75-7 E <br /> JOB ADDRESS A LOCATION_jVP_.A'.�t�I'- _� ...0*1%' � = -G -- --------------------------- <br /> -------------------- <br /> C� <br /> Owner's Name- -a. ,------ Phone <br /> -- ------- ------------------------------- ------------------------------------------------- ------ <br /> Address l L..-. f IA'!'t'.-�1 +� -- ------flSl --- <br /> p <br /> Contractor's Name 'G } rr'�- '�� --------------- Phone <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: Number of bedrooms <Number of baths _ ""Lot size ---- <br /> ---------------------------__________________________________ <br /> Water Supply: Public system ❑ Community system ❑ Private 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--------------------I No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: J <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 depth..------- - -----------Capacity---------------------- <br /> Disposa field: Distance from nearest well.-.- _e'.._Distance from foundation___._t_m.........Distance to nearest lot line.-------------- <br /> Number of lines-------------I---------------------Length of each line-----------�-------------.Width of trench....;!-_--------------------------- <br /> Type of filter material--------5.A...._.__Depth of filter material__L.'r_ -------------- otal length__"X0_'_____________________________ " <br /> Distance to nearest ____Distance from foundation----1.a-`.------Distance to nearest lot line__.+__'4...... <br /> Number of pits----------I----------Lining material_______-5_A_.1....Size: it ----Dept h----/..s_-"_--_____ � <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material--------------------------------- <br /> El <br /> ------.-__.-- -----.__._❑ Size: Diameter----- --------------- ----------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest weEl-----------------------------------------------._Distance from nearest building----------.----------------------..-----_. <br /> ❑ Distance to nearest lot line--------_---------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe)------- -------------------------------------------------------------- --- <br /> ------------------------------------------------------------------------d>�'o---I--------�'-` ��------- ----------- ---------- ---------------____------- <br /> . <br /> -----------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> 1 hereby certify that I 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 the San Joaquin Lcca ,Health District. <br /> (Signed)----------------- -------� and/or Contractor] <br /> BY= --- --------------------'---- ----- ------- ---- ---- -------- ---------(Title)-----------------------------._.-------- ---- -- ------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - --- --- --------------------------------------------- DATE--- <br /> REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------------------- DATE----- --------------- -•--------------------------•--------- <br /> BUILDINGPERMIT ISSUED-------------------------------------- ----------------------•---------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations-------- ------ ------- -------------- - - -----------------------------------------------•-----•-•-----•---------------------------------------------------- <br /> ------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -- -------------------------------------------••-------------- ------------------------------------------------------------------------------------------------------------------ ------------------------------------ <br /> ------------------------------ ------ -- ------ - ----•------- ------- -----------------------------•--------------------------------------------•----------------------------------- -------------------------------- <br /> ------I---------------------- <br /> ------------------------------------------------------------ -------------- ------------ --------------------•--------------- ------------------•----- --------------------------•----------------------------•------------- -------------------- -•---- <br /> FINAL INSPECTION BY:... ._ --------- Date---v1 d ~r ----- ---------------------•-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi, California Manteca,California Tracy,California <br /> r".P.C C. <br />