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FOR OFFICE USE: <br /> ------------------------------------------ ------ ---- - <br /> .......... _____________________ ___________ _ APPLICATION FOR SANITATION PERMIT Permit No. <br /> ----------------------- -------•---• ------ - (Complete-in Duplicate) <br /> -- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct an in!tall the work hgrein described. <br /> This application is made in compliance with County Ordinance No. 549. �51 <br /> JOB ADDRESS AND ORATION. -DF---- - -- ,: �! <br /> OwnersName------.--- -- _ - - - ----------------•---------- - -- --------- - �---------------------- --... Phone_..-----------------------------•--- <br /> Address----------71�----- --•-- --� ------------­------------- --- <br /> Contractor's Name----------- -------r --- a-. <br /> ----------- ---- ---- ...... Phone----- --•------------------------- <br /> Installation will serve: Residence ['Apartment House [] Commercial [❑ Trailer Court ❑ Motel ❑ Other Ej <br /> Number of living units: __/__ Number of bedroom_... Number of baths _.?<ot size ----------------------- <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 ❑ 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 /> . _, <br /> Septic T "k: Distance from nearest well_ -Q�?_�._Distance from foundation----J!_!-----Material _____4f --- - ------ <br /> No. of compartments <br /> --------- ----..._Size _ _ _- 'Liquid depth_-------...--- --- Capacity -- - <br /> -�--- ���- -� ---..Ca acct ���JG-S�-- <br /> Disposal field: Distance from nearest well---1......_ ...Distance from foundation-----/.P..........Distance to nearest lot line_. ------------ <br /> Number of lines ----------.-_____ ___________Length of each line._ ___1�- _�__._._____._-Width of trench. -. -'-__.__-__________... <br /> Type of filter materiai--------1�5.RR_a----Depth of filter material-----1'!_`--____..Total length____';-_ p________________ _______ I <br /> O <br /> Seepage Pit: Distance to nearest well.___------------------Distance from foundation--------------------Distance to nearest lot fine____....___._._.. .� <br /> ❑ Number of pits.-- --.------------.--Lining material---------------------- Size: Diameter...--------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well _______________Distance from foundation__..__------..... . Lining material_____.._____..._____-_______________ <br /> ❑. Size: Diameter_ __ _____________ <br /> - --- - ---------bepth----- - ------ -----------------------------------Liquid Capacity- ------------ - --------gals. <br /> Privy:, Distance from nearest well---------------------------------_.-------------Distance from nearest building--------------------------•--------------- <br /> ❑ Distance to nearest lot line ---------------- - ------ -- - -----------------------------•---------- <br /> Remodelingand/or repairing (describe}---------- ------ - -- ----------------------------------------------------•----------•-----•-- -••----------- ---------------------•------------------- <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 ru s and regulations of the San Joaquin Local Health District. <br /> (Signed) - ------------------•---------- �d/or Contractor) <br /> RY:-------------------- -- - - ----- ---- -------------------------(Title)-- - ...... <br /> (Plot 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 BY------T_-P ---- �-_C .__ -/' ----------------------- ---.---------- DATE.....L. _�_., _T�_ - ------------ - <br /> REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE--- -------------------------------------------------- ----- <br /> BUILDINGPERMIT ISSUED------- -- ------------------------------------------- ----------------- ---------------------- DATE----------------------- --- --------------------------------- i <br /> Alterallionsand/or recommendations----------- ------ - ------------------------- -- -------------•----------------- -------------------------------------------------------- <br /> ---------- :------------------------ ---------------- ------------ --..........• --------------------- ------------- -------------------------- ------------------- ------------••------••----------------------- <br /> FINAL INSPECTION BY:.. re Date..... . ---- --7---.& , <br /> --------- <br /> SAN JOA/QUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Ho:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi California Manteca, California Tracy,California <br /> E.N.9 2M 1-67 Vanguard Press <br /> I � <br />