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FOR OFFICE USE <br /> -------------------------------- <br /> -------------- - ------------------- ------- APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------------ ------------------------------ (Complete in Duplicate) 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 ADDRESSAN LOCATION-. (o �""-- t . X4_40 <br /> ---- - ---- ----------------------------------------- <br /> Owner's Name. f---� W- 4-------------------- -------- ----- Phone------------------------------------ <br /> Address -------- ! -------- ... <br /> Contractor's Name-------- !,� --5------------------------------ ------------------------------------------------- --- ------------ Phone----------------------------------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---t--- Number of bedrooms-j----- Number of baths ... Lot size -// < �i."----------------------------------" <br /> Water Supply: Public system El Community system E] Private Depth to Water Table /z_�t. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe Pq-o�ardpan ❑ <br /> Previous Application Made: (If yes,date)/._ .__-) No ❑ New Construction: Yes ❑ No rf!r 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 T ka Distance from nearest well-----------------Distance from foundation____-- ---------- ------------------------------------------------- - <br /> ❑( -� No. of compartments--------------------------Size--------------------------------Liquid depth---=----------------------Capacity----------------------- <br /> DisposalFiel� Distance from nearest well.______----------Distance from foundation--------------------Distance to nearest lot line-.-.------------- r <br /> ❑ Number of lines---•-------------------------------Length of each line-----------------------------.Width oftrench----------------"------------------ 6' <br /> Type of filter material--------------- -.-Depth of filter material-----------------------Total length------------------------------------------ <br /> SeepPik Distance to nearest well---/44._____.__-__Distance from foundation.la�_--_-....Distance to nearest lot line-�_----------- <br /> 42 Number of pits---1-----------------Lining material"-IZQ(-_-t-------- Size: Diameter_W-i-----------Depth-----�ZsS_-- <br /> Cesspool: Distance from nearest weft-----------------Distance from foundation....................Lining material .....____._______.___...".....".... <br /> ❑ Size: Diameter----- --------------- ----------------Depth------ ---------------------- ----------------------Liquid Capacity----------------------------gals, all <br /> Privy: Distance from nearest well--------------------------------------.------....Distance from nearest building----____---.-.---------------._...._..._. s- <br /> [❑ Distance to nearest lot Iine----------------------------------------------------------------------- -------------------- ------------------------------------------------ A_ <br /> Remodelingand/or repairing (describe):--------------------------------- ------------------------------•-------------------------------------------------------------------------------------- �. <br /> ------------------"----"-"------------------------------------•--------------------------------------------------------------------------------- -----------•----------------------------------------------------------------- <br /> ------------- ------------•--------------------------------------------------------------------------------------------------------------•-------- ---------------------------------------"----- -------------------- -------- <br /> ------------------------­---------------------------------------------------------I------I---- <br /> -------------------------------------------------------------------------------------------------------------------- --------------------------------------------•------------------------------------------------- --------------- P <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 /> Owner and/or Contractor <br /> (Signed) --------- - ---------------------------------------------- -- --------------- - - ------ ------ ----------- ( / ) <br /> By:------------------- --------(Title)------------------------ --- .......... <br /> ------------------------------------------------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY / <br /> APPLICATION ACCEPTED BY---- -- -y--------- - ----------------------------------- DATE. � L ..G �� ; <br /> REVIEWED BY ------------------------------------------ DATE-------------------- <br /> BUILDING PERMIT ISSUED----------------- -- /--- -- DATE. <br /> Alterations and/or recommends+ions: 1� ---------------•------------------------•-------------- ------- <br /> r <br /> ---------------------------- -------------------- -------------------------- - - --------------------------------------------------------------------------------------------------------•----------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ------------------------------------- <br /> --------------- ----------------------- ------------- -- ---------- ----------------------------------------------------------------------------­------------------------------- ------- ---------------------- <br /> FINAL INSPECTION BY:. ------------------------------------- Date--- ----lzl _1_30� <br /> ----------------------------- ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Ha:etton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F.P.CO. <br />