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I FOR OFFICE USE: <br /> --------- <br /> ---------- <br /> -----.__________ ----- ---------------------- _ APPLICATION FOR SANITATION PERMIT Permit No. <br /> r - r ----------------------------- --------- (Complete-in Duplicate) <br /> This Permit Expires T 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. S49. <br /> tttl��� a " <br /> JOB ADDRESS"A LOCATION_ J i� ,4 <br /> Owner's Name------- -- - - - -- - - ---•-----/� - � ---'-- -. Phone_.7.'- ---� .��_ § <br /> Address............. � 2 <br /> --------------------------------•-----••--------•----------•------------ <br /> Contractor's Name--- --..._ '-- r. - = ' /7�, --------.-. Phone----•---••-----------_--. <br /> Installation will serve: Residence Apartment.Hbuse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑j <br /> I Number of living units: j___ Number of bedrooms.,;____- Number of baths-/--- Lot size ��� /�.-_-��--------------- <br /> Water <br /> ----- ----Water� Supply: Publics stem Community sty <br /> stem 50 Private ❑ Depth to Water Table ------ - ft <br /> Character of soil to a depth of 3 feet Sand ❑ l Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobejg Hardpan ❑ <br /> Previous Application Made: llf yes,date_-_ _..-_...:___._ ) No ❑ New Construction: Yes ❑ No X FNA/VA: Yes ❑ No ❑ <br /> E � <br /> i TYPE OF INSTALLATION AND SPECIFICATIONS <br /> f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_________________Distance from foundafion................... Material ----------------- ----------------- <br /> --- <br /> ❑ No. of compartments------------------_ - ---Size------------------- -,---Liquid depth--------- - '- -----._.Capacity ------ <br /> Disposal Field: Distance from nearest well.__.......Distance from foundation_._. <br /> -e!�w_..._Distance to nearest lot I�f_�___.....__. � <br /> Number of lines---------- ___ Length of each line__ -----_- <br /> -' ---- rIC -- 9 �-6-----------'Width of trench-. -- ---- <br /> Depth of'f' material___. <br /> Type of filter material_ p ,� _ __-"-.Total length-2� .. g ' <br /> Seepage Pit; Distance to nearest well__--_Distance from foundation-_Aj---•--_--.Distance to nearest lot l <br /> ine. <br /> Number of pits--- --....__.__Lining matenal.`4 ,sze: Diameter De tn__ <br /> alit <br /> Cesspool: Distance from nearest well _._-----------.--Distance from foundation------------ --- ..Lining material--------_----".____._________-__---- <br /> ❑ Size: Diameter- -- --------- ----- --------------Depth---------'------------------------ -----------------Liquid Capacity-' ------------------------gals. <br /> Privy: Distance from nearest well------------_--------___---__________________+--Distance from nearest building <br /> Distance to nearest lot line ---'--: -- ------------------ ' ' ' - - ' <br /> --•--------------------- <br /> Remodeling and/or repairing (describe):-------- - ------ -----------------------------------------------------------------------' <br /> ---------•---- <br /> ----------------------••--•----- ------------------------ ---- ------------------------------------ -- ----------------------------------------------- ------ ------------- <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 Local Health-District. <br /> (Signed)-----C&`- - <br /> C (Owner and/or Contractor) i <br /> BY ---------------'--------------------------------------------- - ---' (Title) I <br /> (Plot plan, showing size of lot, Iota}' n of system in relation to wells, buildings, etc., can be placed on reverse side), z <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- '-- -�.----- -- --- - ------- -<Z�t--- -------------- DATE_._ _ <br /> REVIEWED BY <br /> --------------- - ----- ----------------------- ------------- DATE----------------- --- ------------------------------- <br /> BUILDING PERMIT ISSUED-------- -----•- ------------------------------- -----' - II =._ DATE----- ) <br /> Alterations and/or recommendations: " ........... " ` -----�- ---- <br /> --" <br /> ----------------- ----•--------------------------------------- ------------ <br /> --------------'........................ -'------ --------------------------- --- - ------------------------- ------------------------------------------- ' '------------- <br /> ----- --'4-------- <br /> x <br /> " ' ' ' - ' ' ' ' - -- ----- <br /> � l Y I <br /> FINAL INSPECTION BY:__. /� ....... Date__.____. <br /> " ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l— 1601 E.Hazelton Ave, 300 West Oak Street 124 Sycamore Street <br /> ' 20.5 West 9th Street <br /> Stockton,California Lodi, California Manteca,,Callfornia Tracy,California i <br /> E.H.4 2M 1-67 Vanguard Press f <br /> I <br /> L <br />