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FOR OFFICE USE: _ I <br /> ------------------------------------------------ -r ��0 � <br />--------------------------------------------------------- APPLICATION FOIt'SANITATION PERMIT Permit No. ............--........- 7 <br />-------- --- ---------- - ........ (Complete-in Duplicate) Date Issued /r-n,l <br /> - This Permit Expires 1 Year From Date ✓�'J�/ <br />_....._..-- ----- --------------------- ---- _ ,,.Issued # <br /> )�_ <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. 1 <br /> JOB ADDRESS AND LOCATIO <br /> _X/yl <br /> Owner's Name--- --------- ---- ---------- -- ------------- ------ ------------------ Phone--•-•-------•---------•----•-------- <br /> Address ------------•---• /----------------------------------------------•--•-•--------------------------- ---------------------------..-..------------ <br /> Contractor's Name-----------------------------------------•--••--• --- -•----------------------------- ------- ------------ Phone------...---------------- <br /> Installation will serve: Residence], Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -- ----- Number of bedrooms -_I- Number of baths---I---- Lot size _±��/ _ ---- -------------------------------- ` <br /> Water Supply: Public system ❑ Community system ❑ Private N Depth to Water Table _).M ft <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel Ej Sandy Loam ❑ Clay Loam.q Clay ❑ Adobe❑ Hardpan <br /> Previous Application Made: (If yes,date- No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <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.................Distance from foundation-----_--------------Material ---------------------..----.------------_--._.. <br /> ❑ No. of compartments----------------------- --Size---------------- --- -----------Liquid depth--------- ---- - - ----.-capacity----------------------- <br /> D;sposal Field: Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line----------------- <br /> El Number of lines-------------------- ------------Length of each line--.---------------------- ---.Width of french----------------------------------- <br /> Type of filter material-------------------------Depth of filter material--------------.--------Total length------------------------------------------ <br /> Seepage Pit: Distance to nearest well.--/�............Distance from foundation---:�(b---------- Distance to nearest lot lineJS--------- <br /> rul Number of pits--- ---I-------------Lining material--- r�,..- -- Size: Diameter....��.r_--_._--....Depth-. ------ 1� t <br /> t <br /> Cesspool: Distance from nearest well ----------------Distance from foundation----------------- --Lining material-.____....-_...._-_---.-_------------- <br /> ❑ Size: Diameter- -- --------- ----- ---- --------- -Depth------------------------------------------- ------Liquid Capacity-_----------------------.--gals. <br /> Privy: Distance from nearest weft-----------------------------__..____.. ------_.Distance from nearest building. <br /> ❑ Distance to nearest lot line - - -- -------------- ------------- - <br /> Remodelingand/or repairing (describe):----- ----- --------------------- -- ---------------------------- -- -•-------------------•---------- --------- --••-- -----•------------------------ <br /> ------------ ------------ <br /> -------•---------------------------------------------------------------------------- _ <br /> _ 'f. <br /> ............................................................................-jam. .__.. -4 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wit17 San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)-- -Z ----- --------------------------------- ---------------------------------- -------- -----(Owner and/or Contractor) <br /> By: ----------------------- ------------------------------------ -------------------------{Titlei----------------- -----..--------- - <br /> -- � ---------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> 3 <br /> APPLICATION ACCEPTED BY �c --------------- -------- <br /> ----------------------------- DATE...../1.-L-/'7.-- ------------------------- <br /> REVIEWEDBY----------------------------------------------------- -------- ------ ------------- ------------------------------- ------ DATE------- -----------•---------- ------•--••--------------- <br /> BUILDING PERMIT ISSUED-------- -- ----- ---------- --------------------------------------------------- --------- DATE. <br /> Alterations and/or recommendations------------------------. --------- - -- - - ---- ----------- -------------------------------------------. ----------------- <br /> -------------------------------------•---------- -------- - ------------- --------------------------------- -------------------------------------------- ----------- -------------------- ------------------- <br /> ------------ ----------- --- ............ ------------ ------------- -------------------------------------- -------------------------------- <br /> FINAL INSPECTION BY:-4_A_ ,r f. ------------------- Date.... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.kaieltan 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 />