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FOR OFFICE USE: <br /> ----------------------------------------------------- --- <br /> --------------------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> - ------------- ------- ------------- --------------- (Complete in Duplicate <br /> Issued <br /> ----------------------------------- -.................... This Permit Expires i Year From Date Issued Date <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construe nd install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION_f�x� ---- C�►�a` "t �� <br /> Owner's Name------ � � l - Phone_.._..- <br /> Address------------------- ------ ------- ---------------- ''`� ---.-------------------------- <br /> Contractor's Name -----•--------•-------••-----------------------••-- ------------------------•-•--•------------------------------- Phone.. <br /> Installation will serve: Residence ffl Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: Number of bedrooms -.3-_._ Number of baths __/__-- Lot size __. HiA----------------------------------- <br /> Water Supply: Public system ElCommunity system ElPrivate g Depth to Water Table -7-C? ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam X 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 240 feet.) <br /> Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material-----.---------------------------------._--____-- <br /> [] No. of compartments--------------------------Size--------------------------------Liquid depth------------------------._Capacity-------------------- - <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line--.__-.-___-_.-_ <br /> ❑ Number of lines------------------------ ------Length of each line------------------------------Width of trench--------------.-------------------- <br /> Type of filter material-------------------------Depth of filter material----------------------- length------------------------------------------ <br /> �Pit. Distance to nearest well--.,3-0------' <br /> ----Distance from oundation___ ^d_________.Distance to nearest lo} line____-____.: <br /> ❑ Number of pits-----Z-------------Lining material-- ........Size: Diameter-S'��.----.-----Depth-----5---------------------- `1'� <br /> Cesspoo#: Distance from nearest well-----------------Distance from foundation------------------- Lining Material-----------.-------------------------- %N <br /> ❑ Size: Diameter---- - ------------------ ------------Depth------------------------------ ---- ----------------Liquid Capacity--------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----..-.______..____.__________----.____. <br /> 0 Distance to nearest lot line---------------------------- --------------------------------------------------------------- ----------------------------- <br /> Remodelingand/or repairing (describe:-------- ----------------------------------------------------------------------------------------------------------------------------------------------- <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, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) �1----------------------------------------------------------- (Owner and/or Contractor) <br /> By:---------------------------------------------------------------------------------------------------------------------------- -(Title)---- <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 /> n <br /> APPLICATION ACCEPTED BY.+!/- ------------------ --------------------------- DATE......_�_Y_~g <br /> REVIEWEDBY------------------------------------- --------------------------------------------------------------------------------------- DATE-- ----- --------------------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------•-•------ --------------- ---------------- DATE---------------------------------- -------------------------- <br /> Alterationsand/or recommendations-------------------------------------- ----- ------------••-------------------------------------------------•--------•--•------------------------------------ <br /> --------------------------------- ------------------ ------------- ----•-------------------------------- ------------------ ------------ ----•--------------------------------------------------------------------------- <br /> ----------I------------------------------------------I--------------------- --- •------------------------------------------------------------------------------------------------------------------------------------------- <br /> Date-LS~ — -(�.�. <br /> FINAL INSPECTION BY <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haielton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stoekloq�California Lodi,California Manteca,California Tracy,California <br />