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FOR OFFICE USE: <br /> _____ __-------------------------- _..__ ------- APPLICATION FOR SANITATION PERMIT Permit No. .. __. <br /> ------------- -------------------------- --------- (Complete-in Duplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued r __ .�� <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 Co fyy Ordinance No. 549. <br /> JOB ADDRESS DLO ATION-_J-�----X------66 ----•---------------- ------ <br /> Owner' <br /> s Name. ---------- ----------•----------------------------------------.-- - - ------------- ----"_ Ph­11one------------------------------------ <br /> Address.......----S.7,34---- -- ­- - --. --•- -3 ------------------ <br /> Contractor's <br /> ---------------- <br /> Contractor's Name-------- t 5S i <br /> ----------••--- -- -------------------------- -------- ------- ---- - -------------------------------- Phone----------------------------------- <br /> Installation <br /> ---•- ----•-----------------------Installation will serve: Residence Apartment House'❑ Commercial ❑ Trailer Court ❑ //Motel ❑ Other ❑ <br /> Number of living units: J_-_-_ Number of bedrooms _2Number of baths I_-_ Lot sizex_/S <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 [5-11'ardpan ❑ <br /> Previous Application Made: (If yes,date_--.---------.----- ) No E'er" 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�l - *� Distance from nearest weft------------- ---Distance from foundation_--_______--_---- Material ____________________________________________ <br /> ❑( , f No. of compartments-- -------------_----__Size__-__.___--____-__- <br /> `�/ - -----------Liquid depth--------- - - -----�---Capacity----------•----------- <br /> Disposal . N: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line_____________.- <br /> ❑( Number of lines.--.-------------------------------Length of each line------------------------------Width of trench_--------------------------------- <br /> Type of filter material----------- --- --------- of filter material-----------------------Total length----_------------------------.------------ <br /> Seepage t: Distance fo nearest well------'----Distance from foundation__Zg__'_._-____.Distance fo nearest lot line-_-�-�___.. <br /> Number of pits___ L----------------Lining' material-__`_R4_C/tSize; Diameter_QA_! -'--_-Depth____ -4-------------- <br /> Cesspool: Distance from nearest well ----------------Distance from foundation....................Lining material__----------------------------------- <br /> ❑ -- -- <br /> Size: Diameter- -------- --- ----------------Depth --------------------- ------- - ----------------Liquid Capacity.-.-----------------------..gals. <br /> Privy: Distance from nearest well------------------------- Distance from nearest building---_-------------------------- <br /> ❑ Distance to nearest lot-line------- -------------- <br /> Re modeling <br /> ------------Remodeling and/or repairing (describe)----- - ------------------ ------------ ----- --------------------------------------------------- -------- <br /> -------------------------------------•------------------------------------------------------•----------------------- - -------------- <br /> t <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)---------------------- 0---------- - ----------- - - --------------- ----- ---------------------------- - ----- -----------------------(Owner and/or Contractor) <br /> By:------------------------------------------------- ------ ----------------- - -------------------------------------(rifle)------------- - - -------------------- -------------- ------ -" <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- - •ice _L��. p� <br /> ------ DATE_ -------- <br /> REVIEWED BY-------------------------- ---- --- DATE.- <br /> ------------------ ---------------------------------- <br /> --------------------------------------------------------------------------------PERMIT ISSUED. -------------------------------------------------------------- ----------------- DATE-------- ------------------ <br /> Alterations and/or recommendations:- ------------------ --- -------------------------------------------•-------------•------------------ - <br /> --------------------- <br /> ------------------------------------------------------------ - ----------- - ------------------------- ----- ---- -------- - ---"----------------------- <br /> FINAL INSPECTION BY:......c '---------------------- Date.---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Ma:elton 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 If <br /> . /I <br />