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FOR OFFICE USE: <br /> _/ <br /> __________________.._.___...______._.____________----- APPLICATION FOR SANITATION PERMIT Permit No. .. �f�r... <br />€ --------------------------------------------------------- (Complete in Duplicate) <br /> ------------- This Permit Expires 1 Year From Date Issued r Date Issued _�l( <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. <br /> JOB ADDRESS AND LOC TION : --- --------y,4/-------V f� _T l ------------ <br /> Owner's Name------------ : r r -•--•-•- `------ ki4i----------------------------------------------------------------- Phone ._;,e' 'C <br /> Address-----------•---------- ��--- -------- = ,�-�.. y--------- <br /> I� <br /> Contractor's Name---- <br /> Installation will serve: ,Residencef Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __/___Number of bedrooms'_ __ Number of baths __l____ Lot size ____--.. <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 /> ou i <br /> Pre Application Previous pp cati <br /> on Made: {If yes,date....................) NoX New Construction: Yes ❑ No R FHA/VA: Ye's ❑ Nog i <br /> t <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: �- <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_________________D€stance from foundation----419---------Material-------__,rem------�,,_a_5,?'"_-----. <br /> No. of compartments----------A--- ���-��---Ld'd <br /> iquiepth----------------- ----------------Size- - --- - ' <br /> Disposal Field: Distance from nearest well.................Distance from foundation-____...----------- Distance to nearest lot line----------------- <br /> E] 4x15r1llj;Number of lined---------------------------------Length of each line_______-__._._,..'..._......Width of french-----.._.---_._-:-_-__.-_._______ <br />` Type of filter mfieriaL________________________Depth of filter material_______ r_ Total length____.__.________---_---_--__-_________ <br /> ,I <br /> Distance to nea#rest.welI--.--__ _ _ <br /> -_-___ _ ___Distance from foundation--------------------.Distance to nearest lot line----------------- 0 <br /> Seepage Pit: Number of pits-- -------------------Lining material----------.------------Size: Diameter-----------_­__=....D.epth...._';._ ----------------------- { <br /> l � s . <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------.------------Lining II ❑ material- <br /> _____-..__--._----.----._.--___---_. <br /> Size: Diameter ___.__.____-------------------- Depth_ Liquid Capacity----------------------------gals. <br /> Privy: Distance from-nearest <br /> well-------------------------------------------------Distance from nearest building._-.-...-___-_________-----------._._--.-. < <br /> ❑ Distance to nearest lot line <br /> ( r <br /> Remodeling and/or repairing (describe):__-�/4__�� j /./(,C.c'----_- !lfp -----' �------------- <br /> O <br /> -------------------•-----•-•--••--------------------•--------- ----------------- <br /> 1 <br /> t ; � H <br /> I hereby certify that"l have prepared Ws"application and`that the work will'be done in accordance with San Joaquin County <br /> ordinances, St and rules and egulati f the San Joaquin Local F-lealth,Di'strict. <br /> {Si ned .--_Ow{ r and/or Contractor) <br /> 9 )---------------- ----- <br /> By: - ° .... {Title) —'� �+ --- --------------- -------------- <br /> - ----------------------------------- <br /> (Plot plan, showing�eize of lot, locati of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY !!�� <br /> APPLICATION ACCEPTED BY `5--------------------- DATE------------ <br /> REVIEWEDBY---------------------- - ------------------------------ ------•-------------------- DATE---- -------- ---� ---- --------------•--------- <br /> BUILDINGPERMIT ISSUED------------------------------------ ---------------------------------------------------------------.- DATE------ ------------------------------------------------------ <br /> Alterationsand/or recommendationsi-------------- ------------ -- -- --- ------ - -------­--------------------- ------------------------------------------------------- --------------------- <br /> ----------_------------------------------------------ ---------I---------------------------------------------------------------------------------------------------•---•-------------------- --------------------------------- <br /> 1 <br /> i <br /> 1 <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:.-- y —�1-- Date - --------------- <br /> S' <br /> S, N JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stotkion,California Lodi, California Manteca,California Tracy,California <br /> F.P.0 M <br />