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IXI --------------------- -----------"I <br /> APPLICATION FOR SANITATION PERMIT Permit <br /> =..... _= ........ ----- . ....... (Completehck <br /> in Du e <br /> P� � <br /> _------_.................. ................. ... This Permit Expires l Year from Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549, f� <br /> JOB ADDRESS AND L9 0 _.. .c'!* :4_'._... _N!� y `� - '='�N=�=- =r`" ---------- ` <br /> . � El <br /> Owner's Name-..._ ._ <br /> erf 3i fi-1 t-------- - ° K, E� --------------------------------------------------------------_-------- Phone------ ------------------------•---- <br /> Address <br /> ..t. c15 -._ �� -------- '----------------------------------------------------- <br /> Contractor's Name--------- . _ _ c?ryi.tc----- - --------------------------------- Phone------------------------------------ <br /> Installation will serve: Residence [� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -_I._- Number of bedrooms._-_- Number of baths ---'—Lot size ..........-------------------------------- .- <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 ❑ Hardpani <br /> Previous Application Made: (if yes,date...........I.._....l No E] New Construction: Yes E] No E] 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 found ation-_-_-..-.--: ------.Material.............-.---.-_ _...................._... <br /> F1No. of compartments---------- ..,..--Size-------------------- ---------Liquid depth---- -------------------._Capacity-:------ ---•------ -- <br /> Disposal Field: Distance from nearest well. ! Distance from foundation..- ./Q............Distance to nearest lot line-.';_.--------- <br /> Number of lines-------------I.........._..-_._.-.Length of each line----.7s...._.....-------Width of trench........ ---.-..------------------ � <br /> Type of filter material-------- ..__Depth of filter material--------ly"_..-.-Total length--------75------------------------ <br /> Seepa fit: Distance to nearest --`- _._....Distance from foundation----_I V_`......Distance to nearest lot line.._'S------ <br /> ..... <br /> Number of pits..........'?' -----Lining material------ -- .......size; Diameter....-.�_3r__..........Depth--_.._.2-..S._---------------- <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 /> i <br /> ❑ Distance to nearest lot line --------- ---------- ---------------------- ------------------------------------------ <br /> Remodeling and/or repairing (describe): ------ ------------------------------------- <br /> ---- <br /> -� rte- <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, rules and regulations of the San Joaquin Local Health District. <br /> (Signed)-,. ---------------- ...................... - Inner and/or Contractor) <br /> 6 `"' -•------'--- - ---; �rlafion <br /> --- -------------------------------------- -----(Title)-------------- ----- - ------_. .. .... .._. <br /> (Plot plan, showing size of lot, location of system in to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_..,I, -- ---------- -------------------------------- DATE__._. ._ --..v1j7-----:------;-------..---- <br /> REVIEWED BY------------------------------ -- •----------- DATE--.------------------------ .------ <br /> BUILDINGPERMIT ISSUED-------- ------- -- ------------------ -•--------------- ------------------------------------------ DATE---------------------------- ---- - --------------------•---- <br /> Alterations and/or recommendations-------------------- - - .............. -------------------------------------------- _-----------------------•--•------------------------------- <br /> • ------------------------------•-- ----- ----------------------------------- ---- ` <br /> --- Da+e -_�-�_...°--------------------- ---------------- <br /> SAN <br /> ----- ..:... <br /> FINAL INSPECTION BY:�-. .- _. _. -�------�------- � - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Streel <br /> Slocklon,California Lodi,California Manteca,California Tracy,California <br /> F.P.CU. <br /> i <br />