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- FOR OFFICE USE: <br /> -- --------------------- ---------------`- -------------- <br /> ----- -------- --------------------------- ------------- APPLICATION FOR SANITATION PERMIT Permit No. <br /> - ------------ ------------------- ---- --I------------ <br /> (Complete in Duplicate) <br /> ------------------- ----------- --- - <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 described. <br /> This application is made in compliance with County Ordinance No. 549 <br /> 4-..t -— r f <br /> JOB ADDRESS N <br /> A CAT ---- -- ---- -- - Z <br /> ------------- <br /> dM 4Owner's Name-------- <br /> - -- ----- - ---- - ----- <br /> Address--------(_!;-Celt_:�­_­ -- ----Z_rp ------------------- ---------- ---------------- ------------- Phone------------------------------------ <br /> ------------- --------- I---------- -------------------------------------------------------------- <br /> Contractor's Name <br /> I--------- ---- --------------------------------------- Phone----•--------------------------- <br /> Installation will jserve: Residence.E] Apartment House F] Commercial 0 Trailer Court [I Motel El Other <br /> I <br /> Nu I mber,of living units. -J_ Number of bedrooms _�Number of baths __/_ Lot size ------ <br /> Water Supply: Public system I E) Community system El Private ER,"DDepth to Water Table ft. <br /> Character of soil to a depthof3 feet: Sand [] Gravel 0 Sandy Loam [] Clay Loam 0 Clay 0 Adobe (] Hardpan <br /> Previous Application Made. '(If yes,date-----------:-------.) No ❑ New Construction: Yes E] No 0 FHA/VA: Yes 0 No El <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_________________Di'stance from foundation-------------------Material------------- <br /> n No. of compartmenls-.---------------------- _Size--------------------------------Liquid depth-------------------- - ---Capacity------------------- <br /> Disposal Field: Distance from nearest well-________________Distance from foundation_______. ......Distance to nearest lot line.__.____-__-___-_ <br /> ❑ Number <br /> ine,---------------- <br /> Number of lines-----------------------------------Length of each line-----------------------------.Width of french-_.------------------------------- <br /> Type of filter material-------------------------Depth of fliter m&erial---------- ------------Total length----------------------------------------- <br /> Seeepe'Pit: D�sfance to nearest well.______/06/ /0 * Ir <br /> ---Distance from foundation------ - ---------Distance to nearest lot line__.__.____.-_..__ <br /> Number of pits--------t.-__-.--_---Lining material----- Diameter----- Dept�___2—Is 1 0 <br /> --------------------------- <br /> V1 <br /> Cesspool: Distance from nearest well---------- ------Distance from foundation--------------------Lining material-_._.___.___-- 7-------------------- <br /> El Size: Diameter----------------------------------- Depth----------------------------------------------------Liquid Capacity- --------------------- gals. <br /> Privy: Distance from nearest well--------------- - - -----------------------------Distance from nearest building___._...______..______----------------------- <br /> F-1 <br /> Distance to nearest lot line---- ---- ---------------------- <br /> Remodeling and/or repairing (describe:-.____._. <br /> ---------------------------------- <br /> ----------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------ ------------------------ ---------------------------------I------------------------- ----------------------------- ------------------------------------------ A <br /> - -----------------------------------------------------------------------------------------------------------------------------------------------------------I-------------------------------------I--------------- ------------ <br /> I hereby certify <br /> Ihave prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State rules <br /> and regulations of the San Joaquin Local Health District. <br /> (Signed)---------------------- <br /> ----- ----- ----------- ------------------------------------------------------------------------------------------------(CO��and/or Contractor) <br /> By:--- ---- ------ <br /> ------------ --- --- -- ------ - --- --------------------------------------------------------(Title)--------------------I--------------- <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 <br /> DATE--------------------- ---- -- - <br /> ---- -------- --------------------------------------- <br /> REVIEWED BY <br /> ------------------­--------- --------------------- ------------ DATE <br /> BUILDING PERMIT ISSUED__---------------------- --------------------------------------------------------------------- DATE <br /> ---------------------------------- <br /> Alterations and/or recornmendaf ions:- ------------------------ - ---------------------- --------------- <br /> ------------------------------------------------------------------------------------ ---------------------------------------------------------- --------------------------------------------------------­------------------- <br /> - <br /> ------------------- ----- <br /> --------•----------- --------------------------- ------------------------------- -------------- ------I------------------ ------------------------------------------------ <br /> ----------------------------------------------- --------------------- <br /> ------------ --- ---------------- --------------------------- --------- <br /> ......... ------------ ---------------------------------------------------------------------------------- <br /> -------------------------------------------- -------------------------------------- ----- <br /> FINAL INSPECTION BY <br /> ----------------- Dafe,_7 <br /> ---------------- --- ------------------------7---------------------- <br /> SAN <br /> ---------------- ------7---------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxelton'Av*. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stocklon,California Lodi,California Manteca,California Tracy,California <br />