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FOR OFFICE USE; Y 1 <br /> APPLICATION FbR `SANITATION PERMIT Permit No. <br /> --------------------------------------------------------- <br /> (Complete in Duplicate) Date Issued <br /> ___..__-__-__._.______________________-------------- ___ This Permit Ex ires 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 compliancewith County Ordinance No. 549. <br /> JOB ADDRESS AND L CATION 14'0- .-if -1)4 ------------- <br /> Owner's Name lgvllal-•-- - - -------------------- -- -- - -------------------- -------------------------- ---------------- - PhoneVI_- ---r®7jI!rZ <br /> Address-------- -------------­---------- ` ---- - <br /> -------------- / <br /> Contractor's Name- _ Phone44_ 4- <br /> Ins+allation wiN serve: Residence ❑ Apar+me ouse ❑ ommercial ❑ TrailerH[6 Motel ❑ Other ❑ <br /> Number of living units: I_____ Number of bedroomsl-`.�Number of baths _Z._ Lot size __________ _________________ <br /> Water Supply: Public system ❑ Community system ❑ Private E--b"epth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe �rdpan ❑ <br /> Previous Application Made: [If yes,date----------- -) No ❑ New Construction: Yes ❑ No R5_--P5_4/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I <br /> t © r <br /> Se is ank: Distance from nearest wel ____Distance from�a�yin Material__.. <br /> No. of compartments- -_ Size_p _�.2 _ __ iquid dep�h__- ...___....__Capacity.____ <br /> Disp al Field: Distance from near st well-�p--- _Distance from found ti P___ __ istance to nearest lot line _._¢-_______ <br /> Number of lines______W <br /> Length of eactt _._ Width of trench.- _.1' ______ _______�Type of filter material_ Depth of filter material--- ---, �`!'----.Total length---- <br /> XSeepage Pit. Distance to nearest well-----------. ----Distance from foundation-------------------.Distance to nearest lot line______________-_ <br /> ❑ Number of pits----------------------Lining material--------- Size: Diameter-----------------------Depth----_.--------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---_-----_----------Lining material------------------------------------- t <br /> ❑ 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 /> `�-- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------- --- ----------------- ---------------- --- <br /> k <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 <br /> ordinances, 'S la rules regulations of the Joaquin Lac I Health Distr t. <br /> --------------------------------- 9�'- ! ! a- <br /> ,_ O <br /> Y -Contractor ! <br /> (Signe 77L ( ) <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 /> DE ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.---------- ` ----- ----- --------------------------------------- DATE-- <br /> �------------------------- <br /> REVIEWED BY----------------------------------- } <br /> ------- -----�- - - ------ ------------- --------------------------------- DATE------ -- -- ------------ ----------- ------- --- l <br /> BUILDINGPERMIT ISSUED-------------------------------------------- - --- - ----------------------------------------------- DATE-------------------------------------------- --------------- ¢ <br /> Alterations and/or recommendations--------------- ---------- ------------------------------------------------------------------------------------------------------------------------------------- <br /> ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ r <br /> ___________________________________________________________________.._-____-___..._____.._.._.__.___._..-._-_---_---_____-_._.___________-_-__-___________...__________..---_____----.____-..___._____.____._______._______-_ <br /> ----------------------------------------------------------_----------_-----.---.---------_....__.__ ._....___-_-_____ .. <br /> ___-..__..___________ ---._____--- ___._ ------------------------ ._ <br /> ___ ..__ _ _ _ <br /> . --h <br /> FINAL INSPECTION BY:- --- ----------------- Date----- --------------------- ----------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1607 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F.P.CG• <br />