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FOR OFFICE USE: <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 construdrend install the work herein described. <br /> This application is made in compliance.T ith County Ordinance No. 549. DS! - 2,00-70 <br /> JOB ADDRESS ANP LOCATION <br /> Q ? <br /> •7�----- <br /> oOwner's Name... Phe. <br /> �Address............... ---- - ... <br /> ;----------- <br /> Contractor's Name.- - - - ------ - ------•----------------------------------------------- Phone.........:.............----•------ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel her ❑ <br /> Number of living units:..___ Number of bedrooms _�__- Number of baths _�__. Lot size ___3- ------- --------6 -- - <br /> Water Supply: Public system ❑ Community system ElPrivate,® Depth To Water Table -S ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ tSandy Loam N Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (if yes,date-----___._-__._-`--__) No•j] 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 II �j <br /> �a-------Distanc from foundation�d Ma erial__ ........ <br /> No. of compartments--- --.--------------.Size_ g,. t --.---Liquid depth- -- -------------------Capac <br /> posal Field: Distance from nearest well-S---- ._.Distance from foundation_-f ------------Distance to nearest lot line. <br /> Number oflines___•-______________'------------- Length.'ofteach line----- <br /> Di2-0 sposal <br /> Width of trench.. <br /> Type of filter materialf�_ .Depth of;.filter material____1_Q_�'________Total length__ �___________________________ <br /> Seepage Pit: Distance to nearest well---w_________________Distance.4rom foundation-------------------.Distance to nearest lot line................. <br /> [] Number of pits.-•-------------------Lining material---I----•-------------Size: Diameter----------_-----------Depth.-------------•-••-•----•-•---... <br /> Cesspool: Distance from nearest well_________________Distance from foundation-__.----------------.Lining material__..-_-.__..________-:_.—_____----- <br /> ❑ Size: Diameter-----------------------------------•--Depth---------------------:--------------------- ------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------_---------- _ --- --------- ------Distance from nearest building_____-_--_._______-.._.______;__.--------. <br /> ❑ Distance to nearest lot line---------------------------------------•• -- ------------------­-------------------•---------------•----------•----------------•-------••------ <br /> Remodeling and/or repairing (describe):_____-- ---- <br /> --------------•---------------------- ---------------------...... <br /> ------- . <br /> ----- ---------------------------------------------------------------------•----------- ----------------•-----------•----•-------•------------•-•---------------------------------•--•---•---------•----------- <br /> 1 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 egulations of San Joaquin Local Health District. <br /> (Signed) i f ------------------------------: ----------------------------------(Owner and/or Contractor) <br /> plan. showing , i <br /> -----------------------------------size of lot, location of system in relation to wellsbuildings, etc., ..._(Title).-._____.-_,__ .____.s---------------=-- ------------- <br /> (Plot h <br /> p 9 y can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- r ------•------------------------ DATE---f�. t---------------------- ------------------------------ <br /> REVIEWEDBY--------------------------------------------- ----------------------------------------•---------------- DATE <br /> BUILDING PERMIT ISSUED------------------------•--------------------...---------------------------------------------- ------ <br /> DATE------------------------------------- ----------------------- <br /> Alterationsand/or recommendations:---------------------------------------- ----------••-------••----------•--------•-•--•----•--•--•--•----......--------------------------------------------- <br /> --------------------------------•-••---------------. ----------•--••---------------------------------------------------•-•--------•---------••--------•------------------------------------------•-•---- <br /> �,• ( ------- ----------- Date_• '- '/ '���..------•.. ------- ------------------------•--FINAL INSPECTION BY:..eC��--"---`-"'--w-- ---- --- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Weil Oak Street 144 Sycamoro Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8.59 2M 5-62 ATLAS <br />