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FOR OFFICE USE: <br /> _________________________________________________________ APPLICATION FOR SANITATION PERMIT Permit No. /.F�. ...3 <br /> ----------------- ------- -- - --------------- --------- (Complete in Duplicate) 1�D <br /> This Permit Expires 1 Year From Date Issued 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 /> JOB ADDRESS AN LOCATION C_ ��Cz(�xc-ems-/ --}Z!�_<.c 7 � '` = -Cl- -- -r---- <br /> - - ---- <br /> Owner's Name- / a � _.Y_ -<'tf ----------- -------------- - ------------------------------------- <br /> ---- <br /> ------------------------- <br /> Phone <br /> f <br /> ----Address--------- .ta <br /> ContractorsName------------------------------ y. -------------------------------------------------------------------------------------- Phone........................ <br /> Installation will serve: Residence Apartmen 1 House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [_1Number of living units; -------- Number of bedrooms --- Number of baths/-'Lof size .- .-......................................... t <br /> Water Supply: Public system ❑ Community system ❑ PrivateA Depth to Water Table f-. ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ElClay Loam [I Clay ` Adobe [:I Hardpan F] <br /> Previous Application Made: (If yes,date....................) No (( New Construction: Yes No ❑ FHA/VA: Yes ❑ No x <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 weal.... - .-..Distancerom foundation.-.-./ .-...M tertaL....:_ ..*.!..�. ...-�� <br /> No. of compartments----- -----.__--------Size----`?--. -------X—Aiquid depth .. ' .- ----Capacity..f-_��---_— <br /> U <br /> _ � ... <br /> Disposal Field: Distance from nearest well_-__ __ ___.-..Distance from foundation... �.-...--.Distance to nearest lot Gn.e_.-_.� <br /> -_. <br /> 4 Number of lines--- s...........................Length of each ....--.Width of trench-----a2_ /---/_0------------- <br /> Type of filter Depth of filter material_..t .- -------Total length-._.)------------------------------------ <br /> Seepage Pit: Distance to nearest well....f . '.__._Distance//fffrom. foundation----9-(9__-------Dist�nce to nearest lot�ine----- <br /> rNumber of pits.....rl.._--.-------Lining material.` ---�-_Size: Diameter..-. _...._____..___Depth-_....Ct..................... <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.-............------------__----------.--- E <br /> ` Distance to nearest lot line__-- ----/-�-.--- 1 --------�-�-c_ --------- <br /> ...f .� _ 4. , <br /> Re oyde�lingf..and/!or repairing (describe.: --� ---------- � � ----------�/�--�-�t- ----•--------- ----------------­-- <br /> --- <br /> ------------ - ----- <br /> ' ' --------------------- ------ --------------------------------------- <br /> ----- -----=- ---------- -•=>r�------------------- -- <br /> ..... ------ ._..------� --r{ --- <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_,la s, ant{ rules and re ulations of the San Joaquin Local Health District. <br /> (Signed)------ _----- ....................... .---.Owner and/or Contractor <br /> By (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 /> -------- - <br /> REVIEWEDBY--------------------------------- -----------..----------- -------------------- ----- DATE__... Y <br /> BUILDING PERMIT ISSUED------------------------------------------------ - - --- <br /> -------------------------------- ------------------- ----------. DATE-----------------------�----- --------------- <br /> -- <br /> Alterationsand/or recommendations:-•------------------------------------------------------------.-------- ------------------------------------••--------•-------••------------------------------ <br /> ---------------------------------- --------------------•-------------------------------------------------------------------------------•--•-------------•--------------------•----------•------------------------------- <br /> --- ---------------------------------------------------- -- ---- <br /> - •--•---.r.. <br /> } ------------------------------------------------------ <br /> ----- --- -------•--------- ---------- <br /> FINAL INSPECTION BY:-- --- •..-- y':`----------- Date------- ----------------------- -------------'��---------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED 8.59 3M 3-'63 F.P.gp. <br />