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FOR OFFICE USE: <br /> - -------------------------------------- --------------- �3 <br /> --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .....-------.___------ <br /> - -- - -- - --------------------------------------- (Complete in Duplicate) _ lyZ 6 <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 ompliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION--- 4,--re --- -=--._---------- -- `------`------- - =-- <br /> Owner's Name--- �� --• ----!`� I `-t 1 /--------------------------------------------- ----- -- Phone----------------------------------- <br /> Address....... "1`�'f ----- ---r -------------- ---------------------------------------------._.._..-----------. <br /> Contractor's Name.-.-_--------------•----- Phone <br /> -- <br /> Installation will serve: Residence ®^' Apartment Ho e ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___�_!-_ Number of bedrooms .__Number of baths ___4-. Lot size .-------��__ A------------------------------------ <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-------- ) No x New Construction: YesOLNo ❑ 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 /> ' A <br /> Septic Tank: Distance from nearest well---�4------Distance�froc fjounda�o _I_,;� ---------Material__.- ------- <br /> Ca acit p� y ______.- <br /> ' 1 No. of compartments___.__'��-----------Size__'�.._!�`___ __..___�_�_Liquid depth____ =s'._:��� .__ _ ,�`•_____ <br /> Disposal Field: Distance from nearest well-fB-q----Distance from foundati ,n... ._ Distance to nearest lo. line----A�_____- I <br /> Number of lines ---- ,r` <br /> __---.Length of each lin -___�___-----_���-f/Width of trench... <br /> Type of filter material!--_1` "' -_Depth of filter material-__�_ �___Total length_______________ __'�"..... <br /> Seepage 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------------------------------------- J <br /> Size: Diameter <br /> ---------Depth------------------------------------- -------------Liquid Capacity ------------ IS. <br /> Privy: Distance from nearest well --------------_-______-_--____--- _._Distance from nearest building---.--------------------------.._ ------ <br /> ❑ Distance to nearest lot line-----------------------------------------------------------------•--------------------------------------------------------------------------- <br /> Remodeling and/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, ands les an regulations of the San Joaquin Local Health District. <br /> (Signed) <br /> a / ____�: _ ____Owner and/or Contractor <br /> " 1 <br /> By: ---------------- - --------(Title)------------------------------------------------ -- ---- - <br /> (Piot 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----------------------I——--------- ------------ ------------------------------------------- DATE---------------------- - <br /> REVIEWEDBY--------------------------------------------- ------------ -----------------------------------------------= r' ._ DATE-ft_ ----------•------------ <br /> BUILDING PERMIT ISSUED-------------------- - -_ --rDATE____.-_.-----------------_---__-- <br /> - ---------------------------- <br /> Alterations and/or recommendations--------------- ---------- --------------------•------------------------------------....---------------------•--------------.------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------ ---------------------------- <br /> ------------------------•------------• ----- ------- - <br /> _ <br /> FINAL INSPECTION BY:..------- - -/ `f `==------- -------- -------------- Date------------A'-- -------------- ` <br /> ---------------------------- --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,Callfornia Lodi,California Manteca,California Tracy,California <br /> FS 9 REVISED S-S9 3M 3-'63 F.P.CO. `y <br />