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FOR OFFICE USE: <br /> ----- ------ - - -------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> _. ------ <br /> !,`------------------------ --- - - (Complete-in Duplicate) Date Issued <br /> .._....._. This Permit Expires 1 Year From Date Issued <br /> - - - <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 <br /> No. 549. <br /> JOB ADDRESS AND LO ATION------ ----- -- ----- Z -••- - - ---- ------- -•------------•---------------------------'--------------u---------- <br /> Owner's Name------------ - ------- - - - ------------ -- ----- -------------- Phone--- <br /> Address------------------------ ---- ! ------------------------ ._ .. ...... - '�'----------- --------------------------------------- -- ----------�----------�-- <br /> Contractor's Name--------------- - -- ------------ ---- ------------- - ---- -.......- ----------------------------- .Phone -- ` <br /> Installation will serve: Residence ❑ Apartment House []-Commercial ❑ Traiier Court Ej Motel ❑ Other ❑ <br /> Number of living units: _- ----- Number of bedrooms-_--__ Number of baths_______ Lot size _____ __ ________ ---_---- ______ _____________________ <br /> Water Supply: Public system ❑ Community system ❑ 'Private ❑ Depth to Water Table _--___ it <br /> Character of soil to a depth of 3 feet- Sand ❑ 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 com partments__ ___--- ______ __ _ ---Size--------------- <br /> ----- -- --------Luid iqdepth--------- - ..... ....... Capacity----------------------- <br /> _ _ _ _ _ <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-------------------------.--------- lJ�t <br /> Type of filter material_________________________Depth of filter material---------------.____.Total length------------------------------------------ <br /> r i <br /> Seepage; Pit: Distance to nearest well-------..-------------Distance om undation_x_e�-------Distance to nearest lot line_-_��.___._ <br /> Number of pits __- Lining material--_ ____ Size: Diameter._____ _ <br /> p I----- - Depth------,y- -------------- <br /> - <br /> Cesspool: Distance from nearest well ----------------Distance from foundation................_ _.Lining material--------_--------_.-_---__.-- --_. <br /> ❑ Size: Diameter- -. ------ -- ----- - ----- - --Depth----- --------- -------- - Liquid Capacity- --------------------------gals. <br /> Privy: Distance from nearest well-----------------------------------------:-__t-Distance from nearest-building-------------------------------..---_----. <br /> ❑ Distance to nearest jot line --------------------------- ----------------------------------------- ------------------------------- ------------------------ - -------- <br /> Remodeling and r repai ing (describe)---------------- ------ ---._- l,]._.._.____ <br /> S <br /> ____________________________________________________A_____--._____..---______---__.__ __---___----_____---_-_-_-___-__-----_-_----__.._.---___e_-___I__tt_________---....__-..------..___.-__---_---- <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 s, and rules regulations of the San Joaquin Local Health District. <br /> wrier and/or Contractor)(Signed) .-_ ___O <br /> --------- <br /> By:-------------------------------- --------- - -- ----/--------- <br /> ------(Title)---------------- -- -------- ---- - - - <br /> (Plot plan, showing size of lot, location of sys n relation to wells, buildings, etc., can be'placed on reverse side). <br /> FORD TMENT USE ONLY <br /> APPLICATION ACCEPTED BY - •- - --- --- ' ------------------------------ DATE---- -- <br /> REVIEWED BY------- ------------------------------------ ----------------- -------------------- - ------ ------------------------------ DATE . ............. <br /> --- --------- - ----------------- <br /> BUILDING PERMIT ISSUED-------- -------------------------------------------------------------------------------------------- DATE--------- --------------------------------------------------- <br /> Alterations and/or recommendations:--- ----------- - ------------ - - --- ----------------------------------------------------------------- ------ <br /> ------------------------------------ -- ---------------- ---- -------------- •- ---------------------------------:-------- ---•---------- <br /> ---------- ----- <br /> le <br /> ---------------------------------- --- ----------- - ------------- ---- -------- - ------------------- y------------- ----------------- ----------- --------- ---- ---------------------------- <br /> ------------------------------------------------------- --- ---- -- ---..._.....----- ---- ---i--------- ---- ------- --------------- ----------- - - -- ----- <br /> F <br /> ` . <br /> FINAL INSPECTION BY:- ----- --------------- - ---- - -------- '` Date._........ F <br /> --_ . <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi California Manteca,California Tracy,California <br /> • E.H.9 2M 1-67 Vanguard Press <br />