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FOR OFFICE USV <br /> ------------- --------- <br /> 4 APPLICATION FOR SANITATION PERMIT Permit No. .4 <br />------------------ -------------------------------------- (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. 549. <br /> JOBADDRESS AND LOC6TI0,N------.Z/IV----- � fir------ ................................................................................................................ <br /> Owner's Name.-------- <br /> ...........I�Z�---------------------------------------------­­-------------------------------------- Phone.................................... <br /> -- .................... <br /> Address......... --------------------------------------------------------*--------------------------------------*------*-----------------*--------- <br /> ------------------- <br /> Contractor's Name..... ............... Phone. <br /> . . ... .............. ----_----- --------------------------------......................... <br /> ----------- ....... <br /> Installation will serve: Residence E5- Apartment House [] Commercial [3 Trailer Court [3 Motel [3 Other [3 <br /> Number of living units: .._.__. Number of bedrooms Number of baths ...1--- Lot size ..................................... <br /> Water Supply: Public system [-] Community system E] Private U4—Depth To Water Tablec- ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam 0 Clay E] Adobe E]--Hardpan 0 <br /> Previous Application Made: (If yes,date____________________) No 05'- New Construction: Yes B- No El FHA/VA: Yes [:] No 231" <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septi TaAk 1 Distance from nearest well----------------Distance from foundation....................Material................................................. <br /> No. of compartments--- ---------------------Size--------------------------------Liquid depth......-------------------Capacity....................... <br /> Disposo Field: Distance from nearest Distance from founclation..,,.�a/........Distance to nearest lot line..,:.r.t....... <br /> ET Number of lines------- ---Length of each line...._�rV!--------------Width of trench....A.t.-4".................. <br /> �t -- - <br /> Type of filter mat --- ---- -Depth of filter material-__taKA_--------Total length....:4EP............................. --%, <br /> Seepage Pit: Distance to nearest well-_/06............Distance-from foundation--/ho. .........Distance to nearest lot line...,.:�:7 <br /> Number of pits---._I---------------Lining material__70 t.t------Size: Diameter....tV...........Depth-------�rl................. (A <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 /> 0 Distance to nearest lot line----------------- ---------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):------ ---------- ...............................................................................I........................................................ <br /> -------------------------------------------------------------------------------------------------------------------------------------------------­­......................................................................... <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, and rules and regula ' ns f the San Joaquin Local Health District. <br /> (Signed)--------------------------------------------- ------------- ------ ---- - -- --------------------------------------------------------------------------------(Owner and/or Contractor) <br /> By:............................ ............. --------------------------------------------------------------(Title)---------------------------------------- -------- ------------- <br /> E system /�,c buildings, etc., can be placed on reverse side). <br /> (Plot plan, showing size of lot, I n o in r ation to wells, <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------ --- -- --------------- ------------------------------------------- DATE........... ----------------- <br /> REVIEWED BY---------_- ------------- -------------------------------------------------------------------------- DATE.......................................................... <br /> -------------------- -------------- -------------------------- - <br /> BUILDING PERMIT ISSUED--------------------------------------------------------------...................................... DATE............................................................. <br /> Alterations and/or reForrirpendations:. ------ ------------------ -------I.................. 7- .... ... -- <br /> J ----------------- <br /> ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------� .................................................. <br /> -------------------------------------------------------------------------------------------------------------- .............................................................................................................. <br /> -------------------------------------------------------------------------- ------ ------------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION ----------­---------- Date...7 -------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 2M 5-62 ATLAS <br />