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FOR OFFICE USE: t <br /> --------------------------------------------------------- l �r <br /> _________________________________________________________ APPLICATION FOR SANITATION PERMIT Permit No. <br /> ----------------------- ---------------------------- -- (Complete in Duplicate) / <br /> Date issued <br /> ------------------------.....-------------.---------- _ _ This Permit Expires 1 Year From 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 AND LOCATION- <br /> Owner's ------ d d ---------------------------------- --- ------ ------------------------------ Phone------------------------------------ <br /> Add --------- <br /> -- <br /> ------------ <br /> ----- a <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 _.,—Number f baths Lot size _. -- _________________ <br /> Water Supply: Public system C1 Community system ❑ Private Depth o Water Table __._____ ft. <br /> Characfe� of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam Clay Loam ❑ 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 /> � r <br /> Dispos Field: Distance from nearest well_�D-�-_-._Distance from foundation.--/.U__________-Distance to nearest lot <br /> Number of Lines_________ Length of each line___`4� <br /> --/------------Width of trench.--- ------ <br /> t_ _{_ r-1Type of filter material__� __ ,_______Depth of filter matenal___ � ___________.To#al length <br /> Seepage :Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__-________.___.. <br /> ❑ Number of pits----------------------Lining material---------- ------------Size: Diameter-----------------------Depth--------------------------------- h <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______.---_._______-______________-_. =� <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------- -----------------Liquid Capacity----------------------------gals.' <br /> Privy: y Distance from nearest well---------------------------------------------------Distance from nearest building __--_. <br /> ------------------------------ -----------------•----------------------- N n <br /> ❑ Distance to nearest lot line_.------------------------------- ------- --------- -------- 1 <br /> Remodeling and/or repairing (describe):--------- -----=---- ------------ ----------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------•--------------------------- ----------------------------------------------------------------------------------------------------------------------------------- <br /> Y - <br /> _____________________________________________________•_______.____________________________________________--_________________________________________________-_-_____________-________________._..__________._____.___________ <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, Set* laws, and rule and regulations of the Sa Joaquin Local Health Dis+ric+. <br /> (Signed--------- - ---(�------ d/or Contractor] <br /> 13 ----------------- �1l1 6t- R- --�-� <br /> (Plot plan, showing size of to+, location of system to relat n to wells buildings, (Title)_____________�'__________________----_______________ _______ <br /> p g y gs, etc., can be placed on rev ers eaide). <br /> FOR DEPARTMENT USE ONLY �i• ,• f= <br /> APPLICATION ACCEPTED BY_ <br /> r-� ----------------- D T r G . <br /> REVIEWED BY------ ; <br /> Oro• �� <br /> �4r¢• D if i------------------------------------------ <br /> BUILDING PERMIT ISSUED-------------------------------------------------------------------------------------------------='SDA ' <br /> Alterations and/or recommendaf ions:--------------------------------------------------------------------------------------------- <br /> ----------------=------------ -------------------•---------------------------------- -------------------------------- i+ <br /> ----------------- <br /> ;---------------------------------------------------------- <br /> .� <br /> ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ <br /> FINAL INSPECTION BY: �•� 'f�r Date ' f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT', <br /> 1601 E.ffaz•lton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> 55 9 REVISED 9.59 31A 3-'63 F.P.CC- <br />