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FOR OFFICE USE: <br /> -------------------- --------------------- --------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------------- --------__------------ ----- -------- <br /> --------------------I----------------- ---------------- (Complete in Duplicate) 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 compliance with County Ordinance No. S49. I - 2_,60 -33 . <br /> S"a a,.Zj <br /> JOB ADDRESS AND LOCATIOS../i_�_ ...n ------—-----------------------------------I----------- <br /> Owner's Name-----CV91-- ------------- -------------------------------- -- -------- ---------- -- -- ---------I------ Phone------------------------------------ <br /> 7 <br /> Address-.---------- --------------- ---------- ­---------------­---- <br /> ------- -- ---- <br /> Contractor's Name---------- p4i-�-- —------ -- -- --- --------------------- Phone--------------------------------- <br /> Installation will serve: Residence Apartment House E] Commercial E] Trailer Court E] Motel E] Other E] <br /> Number of living units: --- Number of bedrooms__-_ Number of baths ---?�'<ot size ---"I -- -------------------------- <br /> Water Supply: Public system ❑ Community system El Private �epfh to Wafer Table -------- ff. C)? <br /> Character of soil to a depth of 3 feet: Sand [] Gravel [] Sandy Loam [3 Clay Loam [3 Clay ft. <br /> [] Hardpan-0 <br /> Previous Application Made: jlf yes,date--------- ----- ----) No E] New Construction: Yes 0 No El FHA/VA: Yes El No 0 <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_________________Distance from foundation_________________-- Material_______.______.________-_-__-______-_---.--_-_. <br /> ❑ <br /> ateriai-------------- -------------------------- ------- <br /> El No, of compartments----- -------- -----------Size---------------------------- ---Liquid depth--------------- ----- Capacity------ ---------------- <br /> Dis l-Field: Distance from nearest well____ -- <br /> Y0_ Distance frofromfoundation---_?!P-----_.Distance to nearest lot line_'__--_______ <br /> ------- <br /> pw Number of lines--- ----------- ------ ----- ----Length of each lineY-K �_Y of french---.--L--------------------------- <br /> Type of filter material___-_ -AiRs......Depth of filter material------/.!F-v--------Total length------11-7------------------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-------.--..----. <br /> ❑ <br /> ine---------- ------ <br /> El Number of pits----------------------Lining material------------- ------- Size: Diameter--------------.--------Depth-----------------_-------------__ <br /> Cesspool: Distance from nearest well-______________Distance from foundation...-_._.-______.... Lining material-- - - ------------------------------- <br /> El Size: Diameter----- - ------------- ----------------Depth---------------------------------- -----------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building___.______--__-_____________--_--____-_. <br /> ❑ Distance <br /> uilding------------------------------------------ <br /> Distanceto nearest lot line-------- ------------------- ------------- - ----------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing {describe):---------------- -----------------------------------------------------------I------------------------------- <br /> -----------------------------------------------------------------------------41- 4- �'�----------- <br /> 1� -- ---------- ---------------------------------------------- <br /> -------------------------------------­-------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- <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 .Inad rules and regulations of the San Joaquin Local Health District. <br /> {Signed)-------------------- ------ -------------- ------ <br /> ----------- -- ------ - - ------------------------------ ---------------------------�nm------(19w. and/or Contractor) <br /> e 4-2 ff--. <br /> ........... -- ----------------------------- ---- -- -------------- ----- ------- <br /> By:-------- - - - ----------- -- ------------- _i' ---------------(Title) ............ - <br /> (Plot plan, showing size of lot, location of system in rela ion to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- ;:�7�_ -------------------------------------------------------- DATE---- ------------------------------ <br /> REVIEWEDBY------ ---------------------------------- --- --------------- ----------- ------- -------- ----------------------------- DATE. •---- --------------------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------- ---------- ---------------------------- ------------------ DATE------------------------------------------------------- <br /> Alterations and/or recommendations:------------------------ ----------- ------------------------------------------------------------------------------------------------------------------------ <br /> -----------------------------•-------- --- ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------- <br /> ------------------------------------------------------------------------------------- -------- - -------------------------------------- -------------------------------------------- --------------------------------------- <br /> ----------------- ------- -------­ �----­­------ ---- I---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------- .........­------------------------------------------------------------------- ------------------------------------------------------------I------------------------------------------- <br /> - - --------------- - --------------- --------- ----------------------------- <br /> FINAL INSPECTION BY:..... Date.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hareltan Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br />