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FOR OFFICE USE: <br /> -------------------- ----------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. --__.j` ` <br /> ----------------------- ------ -- (Complete iD <br /> -------------- { omplee n 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 /> pp p y p <br /> This application Is made in compliance with Count Ordinance No. 549. <br /> JOB ADDRESS A OCATIO �Q - `L '`- --• <br /> Owner's Name----- -�---�---•- ----- --------------=------- -=---------- -----•------------- - - - -- --- Phone-----------•----------•-------•--- <br /> �`� <br /> Address t !_f - ----•-- --•-- <br /> -- � r <br /> Contractor's Name-- ---------- -�T� Phone <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ 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 -------- ft. <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--------------------1 No El New Construction: Yes E] , Not❑ 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 /> i Septic Tank: Distance from nearest well_________________Distance from foundation_..__________.__-F.Material------------------------------------- -________- <br /> ❑ No. of compartments--------------------------Size--------------------------------Liquid depth---------- -- - - -------Capacity------ ----- <br /> Disposa Field: Distance from nearest well...._✓r-_�-.-----Distance from foundation._____f _.�----Distance to nearest lot line____ ------_____ <br /> Number of lines--------------t---.--- -----------Length of each line--------$d--------------Width of french-----�_�---------------------- <br /> If <br /> Type of filter material-___- -------Depth of filter material ___f__9_---------Total length-----F-0------------------- <br /> ------- <br /> Seep"e Pit: Distance to nearest well__-_-1.A _......Distance fr6rrL foundation------h�t--___.Distance to nearest lot line---S---------- <br /> -Number of pits{ d -----Size: , <br /> �i r_ .1�- -------Depth--4--------------- <br /> Cesspool: Distance from nearest well------------r-Distance_from foundation....................Lining material_._____________-_- <br /> --- <br /> ` ❑ W. rSize. Diameter-�---------------------------'---------Depth---------_ ----------------------- ------------ Liquid Capacity----------------------- gals. <br /> Privy: <br /> 'tDiatance from nearest well---------:--------------------------------------Distance from nearest building----------------------------------------- <br /> ❑ -------------------------------------------- <br /> Qistance.to nearest lot line- ------------------------------=--------- - ------------------------- ------------------ 'Jp <br /> Remodeling and/or repairing (describe):_-- -------------------------------------------------------------------------- --------•------------------------------------�• <br /> `_r - ' ---'------ <br /> -----------------•--- :a , <br /> ' - <br /> t. <br /> _____.-.__.__...__.. <br /> ____________________________________________________________________---_-�___.________________.---_________6____-_____________---_________________________-_�__-__________________-_-________-------. <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, and rules and r tions of the San Joaquin Local Health District. . y T7 <br /> . and/orContractor) <br /> Y <br /> Si ned - _ — .. <br /> [Title)---------------------------------------- ontra---or <br /> By:--- - --- - ------------ ------ ------- ---- ------------------- --------------------------------------- /C1 <br /> (Plot plan, showing size of lot, location of system in relatio to wells, buildings, etc., can be placed on reverse side). 0 <br /> FOR )EPARTMENT USE ONLY �1 <br /> APPLICATION ACCEPTED BY__. _ DATE__�_"__� �G& <br /> REVIEWEDBY------------------------------------------------- -------------------------------------------- ------------------------­- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED----------------- ----------------------------------------------------------------- ----------------- DATE------------'------------------------------------------------ <br /> Alterationsand/or recommendations----------------- -------- -------------------------- ---------------------------------------------- --•--------------------•---------------------------- <br /> --------------------------------- <br /> --------•----------------------------------------- ------------.--------------------------------------------------------------------------------------- ------------ ------------------ <br /> ---------------------- - ---------------------- - ---,----------------- -------------------------------------------••-----•--------------------•---------------------------------------- ----- <br /> FINAL INSPECTION BY:_� � ------------- Date - � -(e <br /> --------------------------------- ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> t. <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> g F.P.CG. <br /> 1 <br />