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APPLICATION FOR SANITATION PERMIT Permit No. .. 1 ... <br /> ------------- -- -- ------------------------------------ (Complete in Duplicate) Dt Issued . -�6 <br /> ...__ . ------ This Permit Expires I Year From Date Issued Zf 2_ ^ 8&6_ <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. 544, <br /> JOB ADDRESS AND V? �A IT ONS_ _ - _= <br /> Owner's Name---------- GPhone <br /> ------------------- <br /> Address-----------------I <br /> 1� <br /> Contractor's Name---------------------- <br /> _C ------------------- Phone----I.,--------•------------------- <br /> Installation will serve: Residence A artment House Commercial Trailer Court <br /> ❑ � ❑ Motel ❑ Other ❑ <br /> Number of living units: -_�-_._ Number of bedrooms _'Y"Number of baths ----- -_ Lot size rft-' <br /> Water Supply: Public system E] Community system ElPrivate �Depth to Water Tablef <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,ciate--------------------) No ly, New Construction:,-Yes ❑ No r FHA/VA: Yes ❑ No + <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public suer is available within 200 feet.) <br /> - -f 9 <br /> Septic tank: Distance from nearest well_._ 0.__Distan 1e fr foun #ion--- ------__.Material-.._.' <br /> • <br /> No. of compartments <br /> ---- ------------ Size- -- Liquid depth----.:�1---7r...>!. .---Capacity _^-. <br /> Disposal Fiel stance from nearest well- Distance from foundation_______-____._•.__.Distance to nearest lot line--------------- <br /> Number of lines-----------------------------------Length of each line----------.-------------------Width of french--------------.--_-----------__--- <br /> Type of filter material---------------------_---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-----._-_---------------------- *r <br /> Cesspool: Distance from nearest well--,.______--_-_-Distance from foundation._._________.____..Lining material_____________________________________ <br /> ❑ Size: Diameter- ----------n---------- -------De th----------------------------------------------------Luid Capacity-------------------In•------galsj <br /> Privy: Distance from nearest well-----------------------------------.-------------Distance from nearest building----------------------------- <br /> ❑ Distance to nearest lot line---------------------------------- --------"- - ---------------------------------- <br /> and/ -reair (dascr ; 01 <br /> - /Remd%�ag— . - ` ----- + <br /> r <br /> ri. <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepared this application and tha the work will be done in accordance with San Joaquin County <br /> ordinances, State I s, and rules and regulations o than Joaquin Local Health District. <br /> [Signed' �—� y -------------- ---- ---------------------------------------------(Owner and/or Contractor) <br /> ---- ----------- - <br /> Ely:-------- -------•-------•------------------------------------------------------ =--------------------------------------------------(Title)--------------------------------------------- -- ---- ------ - <br /> (Plot 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------------------ ------------------------------ --------------� DATE _= <br /> REVIEWED BY - , - DATE,-... ---_-- .....�------------------- <br /> ------------ ------------ ---------- - <br /> BUILDING PERMIT ISSUED------------------------------- ------ ------------------------------------------------------------- <br /> Alterations and/or recommendations----------------------------------------------------------------------------------- -----------•-----------------------------------•------------••------------- <br /> ------------- ------------- -------------- - ------------------------------------------------- --- - ------------------------------------ ------ -------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------- - - ---------------------------------------- ---------------------------------------------------------------------------------------------------- <br /> ------------------------------------ ------------ ---------- -I..... ­�...7 -�e ---I----------- ----------- ----------------------------------------- - ------------------- ---------- <br /> FINAL. INSPECTION BY:.-- ........ -` --------------- Date-----------�--------- ------ ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 4th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F.p.C o. <br />