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FOROFFIjCE USE <br /> ---------- <br /> ---------------------- APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------------- ------------- - <br /> -- --- -�Z--------------- ----:----------------------- (Complete in Duplici%) <br /> -- - ---------------------------------------------------;. This Permit Expires 1'Year From Date Issued Date Issued <br /> Application is hereby <br /> made to the San Joaquin Local Health District for a permit to construct,and install the work herein d6scribe' d. <br /> This application is made.in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND 0 Iva <br /> CATION- <br /> --------------------------------------------- ------------------------------------------------­--I------------------- <br /> Owners Name--- ---------------------------------:__1--------------- ------------- -------------------------- Phone--------------- .................... <br /> Address-------- <br /> --------- ------------ ---------------------------------------------- -------------------------­ ----------- <br /> -----------­------................................... <br /> Contractor's Name---- ----------------------_ --------- -----------------------------------:.... ... --------- ------ Phone............... ...........- <br /> Installation will serve: R6sidence W"Aparfmcint House Ej". 'Commercial El Trailer'Court [] Motel ❑ Other C3 <br /> living units: ZNumber of.bedrooms obaths _, <br /> Number f bh /_ 0 .1 <br /> !�LtiZ'e _) <br /> Number of [IV ---- ;L <br /> Wafer Supply: Public system [Community system El Private E] ,Depth to,WaterTa-ble <br /> .-.. . j- <br /> Character of soil to a depth of 3 feet: Sand E] Gravel F <br /> ],,Sandy Loam E]�Clay,Loa'm' E] Clay E] Adobe ER'--Hardpan <br /> Previous Application Made: (If yes,date--------- ---------) No QT`7"New Co-nstru tio' n Yes ❑ No FHA/ A: Yes ❑ No <br /> c� El Ri-" V <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: t. <br /> (No septic tank or cesspool permitted if public sewei,'is av"ailable4ithin 200 feet.) <br /> Sep <br /> tic.Tan�-. Distance from nearest well-----------------Distance from foundation_____-_------______Material-_----._______-________ <br /> of compartments------ -------------------SjZeL <br /> 101WIV - -----4----------------------I...Liquid dep�h--------------------------Capacity---------------- ...... <br /> Disposal Field: Disfanite from nearest well__________________Distance' from <br /> i <br /> ..-.Distance' from funclaflon...2- <br /> - ..........Distance to, nearest lot line__!t� r.... <br /> Number of lines[ __-___Len 'of each -----------Width of trench.'_,9_'f <br /> - --------- <br /> ---------------- <br /> 'er material' Depth �f filter eol " <br /> 4 1WI-4-1 - -7________________•___:-__-- <br /> .Type of filtmaterial----4P----------Total. I6ngth,_&.1 <br /> S Distance to nearest .01 <br /> st well-------— -__-Distance from foundation....ly -.:--_Distance to nearest lot line_________________ \ <br /> ®� Number <br /> ine---0 ------- <br /> Number of pits--!-----/-----------Lining material._/*%�*-----Size: Diame'ter._&_3/"'.-------�Depfh__-A---$_! "14) <br /> Cesspool: <br /> Distance from nearest well-----------------Distance-from foundation______________ __ Lining material_____._-___.___________--_-______:_-_. <br /> ❑ <br /> aterial-------------------------------------- <br /> r_1 Size: Diameter---I----------------------------------Depth--------------------------------------------- <br /> -------Liquid Capacity---------- •---------:---. <br /> - --gals. <br /> Privy: Distance from n'eare'st well----------------------------------- -------------Distance from nearesf building' ------- <br /> ------------------------------- <br /> ❑ <br /> Distance to newest lot line-- --------------------------------------------- <br /> -------------------------------------------------1-11------------------------I---------------- <br /> Remodeling and/or repairing [describe)______________________ I-------------------------- ------­­------- <br /> ------------------------­­:----------------------------------------------------------------- ----------------------------------------- <br /> IV-------------------------------------- -------------------- ----------­ <br /> -----------------------------------------------------------------------------------------------------------------11------------------------------------------------------­------------------------------------------------- <br /> ------------------------ --------------------------------------I ----------f-------------------------------------*--------------------------------------------------------------------------------------? <br /> I 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)------------------------ ----------------------*------------------------- r Contractor) <br /> -------------------- <br /> _(Tifle - - - - ---------- -- - ---------------- <br /> ------------------------ <br /> By:-------:----------- ------------------- <br /> (Plot plan, showing size of lotjocafi I ' <br /> on of Sysf relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY + <br /> 47 <br /> APPLICATION ACCEPTED BY_ <br /> ---------I------- --- DATE_---------------------------- ------- <br /> REVIEWEDBY------------------------------ 1------------------------------- --------------------------------------------------------- DATE----------------------------------- <br /> BUILDING PERMIT ISSUED----- ---------- --------------------------- --------------------------•--------------------------- DATE.----_-. -------------- <br /> Alterations and/or -------;0 <br /> --­--------------- -------------------: . <br /> --------------------------------------------------------------------------------------------------------------------- <br /> _----------------- ------------------------------------ <br /> 'I <br /> ..........I--------------------------------------------------E------------------------------------------------------------I--------------------------------- --------------------------------------------- .............. <br /> ------------- ----------------------------------:----------------------------------------------------------------------------------------------­-------------------------------------- <br /> ---------------------- ------------- <br /> ------------------------- ---------- ------------------ <br /> .......... -----------------------------------•--•-------._..._.._-_.. -..------------•--•--------- ----------------------------------------------------- <br /> FINAL INSPECTION ----- - Date------- <br /> - - - --- <br /> )SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street West Oak Street <br /> 300 124 Sycamore,Stroe�t 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> EB-9 REVISED 13.59 F,F,C0.2M 6-6D <br />