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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT Permit No. _21'_�_ <br /> ............... <br /> - <br /> (Complete-in Duplicate) r <br /> � 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 /> This application is made in compliance with County Ordinance No. 549. 007" (030--2-;P <br /> Al <br /> JOB!ADDRESS AND LOCATION ----- ' f <br /> �.....------- .........-- 'I <br /> Owner's Name <br /> Phone------------------------------•---- <br /> i- ft <br /> Address ' <br /> --------------------------------------------------------r ----------•-----.-•--- ---------- <br /> Contractor's Name------ --•---------- -----------4-a •-- -----------....-__------ --- -- --------------•--•-- ----------------- 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 d 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 ❑ 44 <br /> Previous Application Made: (If yes,date_----------------- I 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.) ((t <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---------------.-------Total length----------------------------------------- <br /> Seepage Pit: Distance to nearest well_._ -------Distance from foundation__eu./_.--.__..Distance to nearest lot lineld �... <br /> Number of pits...!....------------Lining material-_/,6,r,4_. ..... Size: Diameter....32............Depth_.' _f ---------------- <br /> Cesspool: Distance from nearest well ................Distance from foundation----------------- ..Lining material..............------------------------ <br /> 0 Size: Diameter- ---- --- ----- -------- .......Depth--.------------------------- - --- -------- ------ Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------ --- <br /> ❑ Distance to nearest lot line------- ------ ---------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe)------------------ ----_---_--- ----------------------------------------------- <br /> ------------------------------------------------------------------- ---------- ------------•---------------------------------------------------- --------------------- ---------------------------------------------------- <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 lawsZandd ales and regulations of the San Joaquin Local Health District. <br /> or Contractor Owner and <br /> (Signed)---------- : ( / <br /> k By:-----------------------•-------- ----------------------------- ----------------------------------------------------------------•-(Title)._ ------------- --------------------------------- <br /> (Plof!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 /> APPLICATION ACCEPTED -- ----------------------- --- ---- ----- DATE_ - �� ?------------------- <br /> REVIEWED BY--------------------------------------------- -_----------------------------------- -------------------- ------- --------- DATE-- .---- --------------- <br /> -------------------------------- <br /> BUILDINGPERMIT ISSUED---------- --------------------------- ----------------- -------------------------------------------- DATE----------------------------- <br /> Alterations and/or recommendations:......- -- ------------------ ---••-----------------------------------------------• <br /> --------- - -------- <br /> �'.R! <br /> ------------ -----------------------------------•---------- --- - ------------ <br /> -------------------------------------------------- <br /> ------ <br /> FINAL INSPECTION BY: t.. `------------- Date---Y---=/ 17--- ---- - - ---- - ---- ---- ----------- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Slockton,California Lodi, California Manteca,California Tracy,California <br /> E.H.9 2M 1.67 Vanguard Press <br />