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FOR OFFICE USE: <br /> -------- ------ ------;`--- ---- ------------- APPLICATION FOR SANITATION PERMIT Permit No. <br /> ............. ...... ...... ............. <br /> ---------------­- -- ----------------­--­-- (Complete-in Duplicate) -Date Issued <br /> --- -------------------- ---­-- ------------------------ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the Son Joaquin 'Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinan e No. 549. / <br /> -1 4e�-, <br /> ... ------- -- --------- ------ar-e5?-------------------------------- <br /> JOB ADDRESS AND LOCATION jrW <br /> -------------- --------- - - - - ------- ---------------------------- Phone_k5nzf_9_.t-' <br /> Owner's Name ---------- ------------------------------------ <br /> Address-------Z I/ /_ <br /> ------------------------------ ---------------------- ------------------------------------------------------------------------------------------------- ------------------------------------------- <br /> Contractor's Name------.QZ0t/W_:4._' ...... ..-------------------------------- ------- ------------------------- ----_-------------- Phone---.-kA_ ---------------­74� <br /> -- <br /> Installation will serve: Residence [��Apartmenf House [-] Commercial [] Trailer Court E] Motel Ej Other El <br /> Number of living units: __1----- Number of bedrooms _.1._._ Number of baths._I____ Lot size _31c _______________________ --- <br /> Water Supply. Public system 0 Community system El Private [&—Depth to Water Table Jo_ ft <br /> Character of soil to a depth of 3 feet- Sand [Gravel E] Sandy Loam E] Clay Loam E] Clay Ej Adobe 0 Hardpan 0 <br /> Previous Application Made: (if yes,dcite__...,.. __. -_ - ) No El' New Construction: Yes E] No E;—FHA/VA: Yes Ej No �— <br /> TYPE OF INSTALLATION AND "SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sepltic A�ank: Distance from nearest weli-----------------Distance from foundation--------------------Material --- - -------- ------------------------ ........ <br /> No. of compartments------------------- --Size--------------I------ -----------Liquid dep*____ - - --- -_ - - -Capacity---------------------- � '� <br /> .-. Disposal <br /> Capacity----------------------- <br /> Disposal Fj I Distance from nearest well__Sn.......Distance from foundafion_J' .,.-__--_.Distance to nearest lot <br /> Number of lines--_.I-------------------- -.-...-Length of each kne.J-410-11------ ----_Width of trench--- <br /> Type of filter maferial.��J _ae_,,(-------Depth of filter ........Total length----laa---------------------------- <br /> 00 Seepage Pit: Distance to nearest well....... ..... --------Distance from foundation--------------------Disfance to nearest lot line----------------- <br /> 171 Number of pits--- ------------------Lining material--------------- Size: Diameter------------------.----Depth--------------------------._.___. <br /> Cesspool: Distance from nearest well ----------------Distance from foundation----.------.._.. . Lining material-_._..._______.._._..________._--_ <br /> Size: Diameter - ------- - ----- ----------------Depth-------------------------- --- --- -------- --------Liquid Capacity----------------- -----I----gals <br /> Privy: Distance from nearest well------- -------------- --- ---................-Distance from nearest building._____-___.__..____.________._._.....__._. <br /> Distance <br /> uilding----------------------------------- <br /> Distanceto nearest lot line . - ------------------------------------------------------------------------- -------------------------------------------------------------- <br /> Remodelng and/of repairing (describe)--------- ----------- --------------`---------- --------------------------------------------------------- ----------------------------------------------- <br /> -----------------------------------I-------------------------------------------------------I------------------------------------------------------------------------------------------- --------------- <br /> --------------- -------------------------r-------------- --------- ------------- ---- <br /> -------------------------------------- -------------------------------------------------------------------------------------------------------------------- <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 /> � (�'a� <br /> (Signed)------------,`-'-------------------------------------------- --------------------------- --------------------------.(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 /> 4 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ------ ------------------------------------------------------- DATE------ - 7_7.,Z ------------------------- <br /> REVIEWEDBY----- ---------------------------------------------;-------- ------------ -------------- ------------------------------------ DATE------ ----------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-------- ------------------ --------------------- ------------ ?------------- --------------------- DA-TE---------------------------- <br /> ; or recommendations: ------ -------------------------- <br /> Alterations a d/ e omendaficins: V-------- - ---------------------------------------------------------- <br /> F <br /> ---------- <br /> ------------------------------- <br /> ------------------------- --- --------- <br /> ----------- <br /> ---------- --- <br /> ------------------------------- - ---------- - ----------------------------- ----------------------------------------------- <br /> ................. - - - -- - I. ............. <br /> FINAL INSPECTION BY:.----- ....... ...d----------- Date_,.____j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Maxelton 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 />