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rUK (JI-l-R-E USE: <br /> ------------------------------- <br /> ------------------------------ <br /> --------- ------------------ ---------------------I--------- ----------------- --- APPLICATION FOR SANITATION PERMIT Permit No. ,... <br /> , . <br /> ­ ......... <br /> -------------- -------------------------- ....�z-------- � <br /> ------------- --- ----------- -------- (Complete in Duplicate) <br /> --This Permit Ex fires I Year From Date Issued <br /> Date Issued /7/ / <br /> I------- <br /> Application is hereby made to the San Joaquin Local Heal+h District for a permit to construct and install the work herein -escribed. <br /> This application is made in compliance-with County Ordinance No. 549. <br /> JOB ADDRESS AND LOC ............ <br /> Owner's Name- <br /> --- -------------- --- ------- ----- --- ---------- ------------------------------ Phone-------------------- <br /> Address--- <br /> ---- ---- ----- ---I-------- <br /> cl- -------*------------------------1-------------------------------------- <br /> Contractor's Name. _ _ 4�­ <br /> ----------- --------I---- ---------------------- Phone <br /> Installation will serve: Resiclen6 Apartment House ED <br /> CommercialF] Trailer Court [D Motel 0 Other ❑ <br /> Number of living units: ._._ Number of be'drooms Number f baths --- <br /> I te Zi ----- Lot size ..____> C- --------------- <br /> Water Supply: Public system E] ------Community system. El -Private Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loam E] Clay Loam Ej Clay ❑[j Adobe ❑E] Hardpan, <br /> Previous Application Made: (if yes,d6te-----,,,--- <br /> I No ❑ New Construction: Yes E] No E] FHA/VA: Yes El No El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool p'ermiffed,.if public sewer is available within 200 feet.) <br /> Septic Tank- Distance from nearest w"ll----------------JDistance from foundation--__...____-.-_._ Material <br /> partmenfs-------------------------size------------------------------- ---- ------------ <br /> El No. of co�n' <br /> Liquid depth------------ ------- ----Capacity------ ----------- <br /> e ------- ---------Distance from foundation-------------- <br /> D�spo's8l Field- Distance from nea�rest wellI ------Distance to nearest lot line <br /> EJ Number of lines---;----------------- -----------.--Length of each line--------------------------. <br /> --.Width of trench-. <br /> Type of filter material----- -------j.._------Depth of filter material------------------ ----Total length--------- <br /> --------------------------------- <br /> SeepaAe Pit!' Distance to nearesf,.well....... <br /> ------- ---Distance from foundation. -------------Distance to nearest lot line.-----' <br /> Nu;�gero� pits.----- -/-------I----Linin g material material...._____ ------ Size: Diarnefer---­2j(.........Depth----:2— ------- <br /> .1 :., I (�' "I ---- -------------- <br /> Ce'sspool. 'N�stance . It 1*1� <br /> fromln6re�t well-------- �Distance from foundaf;on--- ----------------Lining material___________________.__..._-..__ ___ <br /> -4, ---------- <br /> El Size: 'Mannefer—, '* �'a <br /> %,� <br /> � ---�-- <br /> Depth---------------------------------------------------L�quicl Capacity-------- - <br /> PriKY. Distance from. nearest well-------- gals. <br /> 1 41 Distance to nearest lot line--------------------------------- --------------Distance from nearest building------------------------------- <br /> ------------------------------------------------------------------------------------------------ -------------------------- <br /> Remoll i ing and/or repairing ( c e):-------------------------- ------------- <br /> ---------------------------------------- -- ------- ------------------------------------ <br /> I -------------------------------------------------------- ------------------------------------------------ <br /> --------------------------- <br /> ! ------------ - -- -- ------- ---------------------------------I------------I------------------------------------------------------------------------------------------------- <br /> ------------------------------------------- -- I----- ------- --------------------------------- <br /> (rr * - -------------------------------------------------------------------------------;--------------—------- -- -- <br /> 1,hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Z <br /> ordinances,&Sfafflaws, and rules and regulations of the' San Joaquin Local Health District. <br /> (Signed).`----- . . ....... <br /> ------ ---- ------ 16wj;;�n d <br /> ----- -- ------------------------------------------------------------------------------------------------- w nd/or Contractor) <br /> $y=--- --------- <br /> -- ------- - -- --- ------------ ----------------------------------------------(Title)---------- ----------------------- ----- ----- - ------ <br /> (Plot plant, showing size of lot, location of system <br /> relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.. <br /> ----------------- -------------------------- DATE.__--- --- <br /> REVIEWED BY ------------- DATE--- ----- -- ----------------------------- <br /> - - ------------------------ --------- -- ----------- ---------- -------------------------------------------- ATE <br /> BUILDING PERMIT ISSUED------------------- DATE <br /> ----------- - ------- ---------------------------------- <br /> Alterations Ad/or recommendations:..._._._-______.._____-------------------------------------------—-------------------------------------- DATE------------------------------------------------------------\ <br /> ----------- --------:- ----- --------------•------- <br /> ------------- <br /> ----------------------------------- <br /> -------------------------------------------------------------------------------------------------------- <br /> -----------i----------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------- ------------- <br /> ---------- ------ ------- ------ ------------------------ ----------------------------------------------------------------------------- --------------------------- <br /> ------------:---------------­ ---------------- <br /> :------------------ ------------------------------------------------------- -----------­------------------------------------ ------ ------------------------- <br /> ------------I -----­-------------- -- ----- ------- -------------- ..........:------------ ------------ ------------------------------------------- <br /> -------------- ---------------------------------------------------- <br /> FINAL INSPECTION BY:- <br /> Dat ......... .. <br /> ..........-_1------------------------- <br /> SAN JOAQUIN LaCKL7HEALTH DISTRICT <br /> t Street X— <br /> . 12 <br /> 1601 E.Haxellon Ave 300 Z'. Oak 4 Sycamore reei <br /> Stockton,,California Lodi,California Ma–h 205 West 9th Street <br /> a t ,California Tracy,California <br /> —a <br /> rZ 9 REVISED a-59 3m 3-,63 p,p.C:0. <br />