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FOR OFFICE USE: <br /> -------------------------------------------------- <br /> --------------------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. .lP. -._y. <br /> -- --------------------------------------------------- (Complel-e in Duplicate) <br /> Date Issued <br /> .____________.______________________ --------- ___ This Permit_Expiresh 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. ® MAMTV-7 CA . <br /> JOB ADDRESS AND LOCATION----- --- --_,,z----- ----- ------ r !..---V4--- •--- --------- <br /> I' - ---- - --- ---- --- -- Phone__ --- _ <br /> Owners Name----��1------�--•�.�-�.�'�--------------------------------------- --- -- - - -- -- - ------ -, - --- t� <br /> Address ` �r'.. -. l•�i--------------------III--------•---------------- <br /> Contractor's Name-----_.._.1fjr4-- -------------------------------------------------------------------- --------------- Phone------------------------------ <br /> Installation will serve: Residence ❑ Apartment House Commercial Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -------- Number of bedrooms ------ll- Number of baths _/-___ Uot size ___________________________________ <br /> Water Supply: Public system ❑ Community system ❑ P�ivate C3-1Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ravel ❑ San Loam ❑ Clay Loam ❑ Cl ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date.............-------) No New Construction: Yes No E] FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tan k`or cesspool-permitted-if-public-sewer i available-within 200 feet:) - <br /> Septic T k: Distance from nearest well--�V --Distance from foundation____1 ------Materi �_____ _______________ _______________ ____ <br /> in <br /> No. of compartments_ _________________Size__j/� �__-_.___Liquid depth_----_ --_.----_- Capacity___,t ___-_-___ <br /> Disposa field: Distance from nearest well U Q----_Distalis ce from foundation-----AO........Distance to nearest lot line.-__-_._--____. <br /> Number of lines---------t............ __11_____Length of each line---,lQ. -____.--------Width of trench---._� __.----------------- <br /> Type of filter mate rial__�_J-4WPiY___Depth of filter material----/_fr----------Total length______ QO_�_-________________ <br /> Seepage Pit: Distance to nearest well______._____________Distance from foundation____________________Distance to nearest lot line----------------- <br /> ❑ Number of pits----------------------Lining maternal----------- -------Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well____-_______.__Dista)nce from foundation--------------------Lining material------------------------------------- t <br /> Size: Diameter- ---------- - ----- ...........De t�--------------------------------------- -----------Liquid Capacity---. gals. <br /> Privy: Distance from nearest well-------------------------til____-_..-________-__._Distance from nearest building----------------------------------------- <br /> ❑ <br /> Distance to nearest lot fine------------------------I------- ------- ------- -------------------------------------------------------------------------------- <br /> Remodeling and/or repairing �---------------------------------•------------------------------- ------ <br /> ---------------••-•------------•------------------------------------------------------ -- -- ----- ------------------------------------------------------ ----------------------------------------- --------- <br /> --------------------------------------------------------------------------------------------------------1 -------------------------------- # <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 IJoaquin Local Health District. <br /> (Signed)--------------------------------------------------- ---------------------------------------- ------------------------------------------------•----- ------------(Owner and/or Contractor) <br /> BY ----------------:-------------------------------:_ _ - - _ (Title) r ,_ <br /> it <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). �1 <br /> FOR DEPARTMENT USE ONLY I <br /> APPLICATION ACCEPTED BY---- ------ 77-•-R—no—- ------------I----- --------- ----------------------------- DATE-------- l j ---- ----------- I <br /> REVIEWED BY--------------------------------- - - ----- -------------------- ) ---------------------------------------- DATE----- -- ----- ----- ---------------------------- <br /> ---------- <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------- ------- ------ -------------------- DATE.--------------------------------- -----------------•-------- <br /> Alterations and/or recommendations:.-- ---------- ---------------------------- ---------•-------------------•----•---------------------------------------------------------- <br /> ----•------------- - ------------------- --------------------------------------------------------•--•----•--------------------------------------------------- <br /> ---------- --------------- ---------------- -- ----------------- -------------------------------------------------- ----------------------------------------------------------------- <br /> ------------------------------------------------------------ -- - ------------- ---- -I)............................. --- ------------------------------------------------------ <br /> ----------------------------- ...... -- - ------ ---- . - ----- --- ---- h -------------- ------------------------------------------------------------------------------------- <br /> FINAL INSP -------------------- <br /> = . -------- -- ------- Date----------------- -- ------ <br /> pu <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy, California <br /> F.P.0 Q. 'te l <br />