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F R OFFICE USE: yrj,`' f L r <br /> r T . <br /> ------------------- ------------------------------------- <br /> -------------- <br /> ------------------------------------ <br /> APPLICATION FOR `SANITATION PERMIT Permit No. ................. ... <br /> --------------- - -------------------- ----------------- (Complete in Duplicate) <br /> ----_--------------------------------------------__._._ This Permit Expires I Year From Date Issued <br /> Date Issued ........ ............ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein de5cribed. <br /> This application is made in compliance with County Ordin rice No. SM. �-�rtiJ bSp` eo -� G 0 �}/ <br /> logo' "1. r~t� �o,.�. +�• _ /fes4 <br /> �c_ 9- xi& F ----•- r------------------ <br /> JOB ADDRESS AND LO ATI N_1v` %_ %_ <br /> Owner's Name------ <br /> • - ----- - -------------- <br /> ------------------ -------- -------------------- ------- -------------- Phone------------------------------------ <br /> -- --- -- - <br /> Address-.......... ' <br /> Contractor's Name--------- ------------------------------------------------------------------•-------- ----------------- Phone---------------------------------- <br /> Installation <br /> --•---•-------- •-------•------.Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __ _. Number of bedrooms _S__ Number of baths .2._._ Lot size � X.. ��--/---------------------- <br /> i <br /> Water Supply: Public system ❑ Community system ❑ Private 9?"'Depth to Water Table -A�Dft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: (It yes,date--------------------) No 123`�'New Construction: Yes �o ❑ FHA/VA: Yes 4�— No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well__d(jr._. Distance Jvom f ndation__. __ <br /> 4Y .r �Z?-------Materia!_�_�. s -- ---------- <br /> No. of compartments___,,?..................Size"0Xr_�X �Liquid depth_�_-.......--------CapacityzxQ__.__..._-_ <br /> Disposal Field: Distance from nearest well-- ----------Distance from foundation---1 4--------Distance to nearest lot line _____ __ <br /> Number of lines-------e---_---- ..__ .____ Length of each line_/?,(,*__/_--+ Width of french--A--/_------------------------ <br /> Type of filter material_ / r Depth of filter material__,el" ---------_Total length---Z— <br /> Seepage Pit: Distance to nearest well- --Distance fro fou daticn__a.4--c'$-------.Distance to nearest lot line______-------.- <br /> (�� Number of pits.._-----.-------Lining material__ .Size: Diamete <br /> r.���__.-_-Depth��" <br /> Cesspool:ool: Distance <br /> a nearest wel -----------------Dstace from foundation--------------------�i <br /> ❑ eDiameter ---------- epth ___ quid Capacity_._._-__ _ - _-..___._.._gals y <br /> Privy: Distance from nearest well------------------------------_._.._.------------Distance from nearest building.__..._______--------------.------___--- <br /> ❑ Distance to nearest lot line------------------------------ ------------------------------------------------------------- - <br /> ----- ---------------- ---12_11-1---------- <br /> JO <br /> Remodeling and/or repairing (describe):-----------� - ---- <br /> ---•-------------------•-------------------------•----------------------------------------------- ------------------- ------------- - ---------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------- <br /> ----------------------- - ------------------------------ ------ 3 <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 r gulations of the San Joaquin Local Health District. r <br /> (Signed).. ! '"' - --- ------------ --- [ Contractor) <br /> ---- <br /> By:--------------------------------------•--------------:---------------------= --- -------------•- - --- - -..--------------(Title)-- L'� <br /> (Plot plan, showing size of lot, location of system in r ion to wells, buildings, etc., can be placed on reverse side). <br /> 0 <br /> FOR DEPARTMENT USE ONLY P <br /> APPLICATION ACCEPTED BY--------------------------- -- - --------------------•••- --------- - -1-C/- DATE ~.�r� SL <br /> REVIEWEDBY----------------------------------------- -------- ------------------------------------- ---------/-------------------- DATE----- ----------------------------------------------------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------•-------------------------------------- DA•TE------ ------------------------------ ----------------- <br /> Alterationsand/or recommendations: ------- ---------------- - -----------•---------------------------------------------------------------------------------------------------- <br /> ----------------------- ----------------------•----------------- ----- - ---------------------------- -------------------------------------•-------------------•------------------------------------------------------- <br /> ---------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY ______ _ __ __ _ ~� �° - ---- <br /> Date... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th street <br /> Stockton,California Lodi, California Manteca,California Tracy,California <br /> F•.P.co. ~ <br />