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�FOR-OFFICE­USE: <br /> - ------------ --------------------- Permit No. _[��f`_-:y�. . <br /> ---------- ------------ -- ----------- ----------- <br /> APPLICATION FOR SANITATION PERM i <br /> - - ------------- ----------- ------ (Complete-in Duplicate) <br /> - Date Issued - <br /> __ -_.__-.._. --_ This Permit Expires 1 Year From Date Issued I <br /> Application is hereby made to the Sen Joaquin Local Health District for a permit to construct and install the work herein described. i <br /> This application is made in compliance with County Ordinance No. 5549.. 1 <br /> JOB ADDRESS AND LOCATION.-)!VIWA_� _..T--C �''"`� � f� `- 'S/--_---- <br /> 9r <br /> L ---------- <br /> --y <br /> - Phone. <br /> {Owner s Name--- D_!T_� ---�i_�_1/L�------- ------------------------------------- --- - - ------ ---------- - �. <br /> Address l �, �� lL .---- ---------- --- <br /> s Phone__ r� 'S--- <br /> -•- <br /> Contractors Name_____ ._ - -�--`�---- """"" <br /> Installation will serve: Residence XApartment House [ICommercial ❑ Trailer Court ❑ Motel ❑ Other El <br /> Number of living units: -_ ----- Number of bedrooms _,a._ Number of baths -------- Lot size _. �Zxt --- ------------------------- <br /> t I <br /> Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Tab4e ------ _ ft <br /> Character of soil to a depth of 3 feet- Sand ® Gravel F1 Sandy Loam El Clay Loam El Clay 1:1 Adobe 11Hardpan E] } <br /> r ) No New Construction: Yes No FHA/VA: Yes ❑ No ❑ F <br /> Previous Application Made: (If yes date_.__...._... ❑ ❑ <br /> .,., ..a. _ — <br />�- ., TYPE-OF-INSTALLATION-AND -SPECIFICATIONS:"`- "` -' <br /> I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Di5fance from foundation-------------------.Material -------------..__-.____..._-__--.---__-----_... <br /> ❑ No. of compartments------ -----------------Size--------- ---------- -----------Liquid depth--------- -- --..--.Capacity----------------------- <br /> Disposal Field: Distance from nearest well-_". from foundation----1_.0--------Distance to nearest log line___-_ <br /> Number of lines,_.___--_ ...�.. � _------_Length of each line-----_--r�-_- -----,,.---.Width of-french... --�____________________ <br /> Type of filter material__./C.D+ - ---Depth of filter material._.."-/_�..--------Total length-.-.-__. --- Q <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot,line--------------... <br /> ❑ Number of pits.-- ---------------.-.Lining material-------------------L..- Size: Diameter-----------------------Dept h_..------- ---------..----------; . <br /> Cesspool: Distance from nearest well -."-_-----__--Distance from foundation................. ..Lining material -.-.-------------------------------.-. <br /> ❑ Size: Diameter- -- -------------- ------- -- ----Depth--------------- -- ------- --------Liquid Capacity-------------- -------------gals. <br /> Privy: Distance from nearest well ------------------.-----------------------------Distance from nearest building.-------------------------------------- <br /> ❑ Distance to nearest lot line-------------------------------- ------------------------------------------------------------------------------------- <br /> --- - <br /> ' <br /> Remodeling and/or repairing describe -------------------------------------------------------- ----------------------------------- <br /> ----------------I------------------------------- <br /> ------------------------------------------------•------------•------------------- -- ------------------------- ---------------- <br /> -------------------------------------------------------------------•-- ------ <br /> ----------------- <br /> I ---------- ------------------------ -----------------------------------------------------:------------------------------------------------•--------------- - -------------------------------------------- <br /> 1 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 an regulations of the San Joaquin Local Health District. <br /> (Signed) ------------------------------------------ ----------------- -- ---(Owner and/or Contractor) <br /> ----` . _ <br /> By•--------- -------- ---------- ------ - --- ---------- - <br /> (Plot plan, showing size of lot, location of system in relati n to wells, buildings, etc., can be placed on reverse side). <br /> ( <br /> �FODEPARTMENT USE ONLY <br /> ri <br /> APPLICATION ACCEPTED BY._-_.ti.-ipk-0------------------------ ------- ------------------------- -------------- DATE. <br /> - <br /> REVIEWED BY. ---.--- <br /> DATE <br /> BUILDINGPERMIT ISSUED-------- -- -r------------------- -- - - -------------------------------------------------- ---------- DATE--------- ------- ------ -------------------- -- ------------ <br /> Alterations and/or recommendations------------- ----.----.... -- -- --------------------------------------- ------------- --------- ----------------------------- <br /> ------- ---------- -------------- ----------- -------- -------------------------- <br /> - ---------- ------------------------------- ------------------------------------ <br /> ---- <br /> ---•-------------- --------------- <br /> i ----- ------------ ----------- --------- <br /> - <br /> ------ -------------- - <br /> FINAL INSPECT` Y Date------- ----- - �� ---- - ----------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hasellori Ave. 30o West Oak Street 124 Sycamore Street 205 West 91h Street <br /> 1 Stockton,California Lodi, California Manteca,California Tracy,California <br /> E.H.9 2M 1-67 Vanguard Press <br />