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FOR OFFICE USE: <br /> --------------------------------------------- ----------- <br /> -------­----------------I. <br /> ------------------------------------ ----------- APPLICATION FOR SANITATION PERMIT Permit No. .,r1. _._ d <br /> (Comple+e•in Duplicate) <br />` __........_... ................ This Permit Expires 1 Year From Date Issued J-rll 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. 549. <br /> JOB ADDRESS A R Q OCATION /��--`---� r - <br /> Owner's Na ----- ------- <br /> ---------------------------- <br /> -•--- <br /> --------------------------- ------ ----- ---------- Phone------------------------------------ <br /> --► �---- ------ <br /> �Lf iouse <br /> -------_-_------- .... -_- -- �- ----__... .____._._ 4Contractor's Name-------- ----------------- ------ ----- '�It�±¢�.----.--. Phone---------------- <br /> ------------------ <br /> Installation will serve: Residence �partment ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> I <br /> Number of living units: N mbar of becJrooms�y�. Number of baths .__.._ Lot size -----_------------­------ <br /> Water <br /> -_..................Water Supply: Public system Community,.syste ❑ 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 /> Previous A lica.+ion.Made:-,;:(If es,.date_--:.;:.___ - )-�-No•-^- .---•New-C�onstruetion:'Yes` \� <br /> Pp Y ❑ ❑"No ❑ FHA/VA: Yes ❑ No ❑ _3 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: p _ <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) `3J <br /> SeptiE'Tank: Distance from nearest well -----------------Distance from foundation--------------------Material..--..._.-___-----.----..---------------..__---- <br /> ❑ No. of compartments-----------=------'.._Size--------- ---------- -----------Liquid depth-------- <br /> ------ Capacity----------------------- <br /> t <br /> Disposal Field: Distance from nearest well,-.............. :.Distance from foundation__..___. --------Distance to nearest lot line----------------- <br /> ...: <br /> ❑ Number of lines. - ) Length of each line Width of french.-.. <br /> Type of filter matorial - --y_=.�.__ I Depth of filter material...._____..q______...Total length------------------------------------------ <br /> Distance to nearest well _/60.r �---Distance-f�m oundation------/_��.._�.Disjance to pearest lot iine---,5---.�_ <br /> �' _ <br /> ❑ Number of pits... - _- Lining material___ --.;�_--_'.. . Size:�iarrrgl�r j f -Dept'n�____-�/ -�-------------- <br /> Cesspool: Distance fr m""neaarest'Veli~~-_...._. _Distance-fiom,found 'fion'...... ........ ..Lining aterial__..._...____...____.__.__ <br /> [] Size: Diameter'------------ Depth-------------- -...... 3 �- ------ - ......Liquid',Capacity- ---- -------------gals. <br /> Privy: Distance from nearest-well---------------- ------------------ -------------Distance from nearest building.------- ---------------------------_---. <br /> ❑ Distance to nearest lot line------- -------- ------- <br /> Remodeling <br /> -----Remodeling and/or repairing (describe): `--- - <br /> ---------------- <br /> oil <br /> __. �` <br /> �"r �`�F' <br /> -------------- <br /> -------------------- - I r <br /> - -------- ------- --- --- <br /> ------------------------ ----------------------- ------------------------------------- -- <br /> .__ _,-__---------------------- -'! '� <br /> ------------------ ______'_____�________._________________________ ---------------------------- _-- .____._____ r <br /> --- <br /> ! hereby cert' ,that I have,p ep6red this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Stat la s, and rules and regulations of the San Joaquin Local Health District. r :-- <br /> Si ned <br /> { g )-------f _ -:` - a <br /> - T — :.:: _ d/or Contractor) <br /> BY:-= = ------ ----- ------------------- ----- --------------------- ---(Title)---------- - ---- -------...------------- -------------- <br /> (Plot plan,-showing size of lot. location of system in relati n to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APP!_ICATION ACCEPTED BY. ------------- DATE__- _ <br /> - --- --- ---------------- <br /> REVIEWEDBY ------- - ----- --------------------- --------------------- ------------------------------ DATE-------------------- <br /> BUILDING PERMIT ISSUED-- ----- --- ---------------------------------------------------------------- ---------------------- DATE-----=---------------------- ------ <br /> Alterations and/or recommendations--- -- --------- ----- - --------------------------------------------- ' ------------------- <br /> -------------------------- <br /> i r <br /> -----------­­----------- ------•--- ' -----------------"---------------------------------------- -------------------------•---------------- ----------------- -- ---------------•------------- <br /> ------------------------------------------- 1 <br /> ------------- - ---------- -------------------•--------------------------- --------------------- ------------------ ---------- --- ---- - ----- <br /> FINAL INSPECTION BY: -- __-- - -------------------- Date.- --- ��-------------- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Ha:ellon Ari. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi, California Manteca,California Tracy,California <br /> LH.9 2M 1-67 Vanguard Press <br /> . i <br />