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FOR OFFICE USE: <br /> ------------------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. <br /> --------------------------- --------1---------------- <br /> ------------------------------------------------ ---------- (Complete in Duplicate) Date Issued <br /> ----------------------------- -------------------------- This Permit Expires I Year From Date Issued ....... <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the.>,Prk• e e* d crib6d-.­ <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATPN.------ <br /> x <br /> -------------------------- --- <br /> Owner's Name--------------------- ---- --- ---------- -------------- - --- - -- --------------------------------- Phone-------------------------------------- <br /> s------------- ------- -------- - -- ----- ------------------------------------------------------------------------- <br /> Addres ------------- --- --- <br /> ------------------------ -------------------------------- <br /> Contractor's Name--------------------------- - - --- - - -------------------------------- ------------------------ ------- Phone. <br /> Installation will serve: Residence Apartment House F] Commercial E] Trailer Court E] Motel 0 Other 0 <br /> Number,of living,unilsa Number of-bedrooms --- Number o baths Lot size ------ ..------------------ <br /> Water Supply- Public system El Community. system El Private epfh to Waf6r Table --- <br /> Character of soil to a depth of 3 feef- ."'Sand E] Gravel El Sandy Loam I-] Clay Loam �.Clay 10 Adobe E] 'H dpan El <br /> Previous Application Made- [If yes,doite--------------------.) No ITNew Construction: Yes,9,No E] FHA/VA. Yes No <br /> ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public se <br /> —,wer. is available within 200 feet.) <br /> rpm'fouviati <br /> Se DiJa' nce from nearest __Distance f Dn,ye)---------- <br /> Material _-_-..L_ <br /> P id depfjri----- ----- Capacify__A,7_-e_1-*e ? <br /> No. of compartments--------- -------Sizel.7,1-- 'rlkll <br /> Disposal I,' Id: Distance from nE,�arest well---�V__ .._Distance from foundation6I -_.. .Distance to nearest lo�)in6----(�----------- <br /> Widfk of trench.__ ------------ <br /> Length of each lin4 1-, <br /> Number of lines- ---------------- 6 <br /> Type o� filter mate ria Depth of filter material--f; -____.Total length_-_._____ ---------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation_-------.---_-__.-- Distance to nearest lot line--.---:-.--.__.-_ <br /> ❑ ''''Number <br /> ine----------- <br /> 'Number of pits----------------------Lining material-----------.----------.Size: Diameter----------------------Depth- - -- --- ---------------------- <br /> Cesspool:- Distance from nearest well-----------------Distance from foundation-_---------------- Lining nnaterial--------------------------- --------- <br /> Size: Diameter------------------------- - Depth-------------------------------- - -:---------------Liquid Capacity--------------------------gals. <br /> Privy: Distance from nearest well__ ---------------------------------------- -Distance- from nearest building____._______--. -. ----------- <br /> ❑ Distance to nearest loft line--------------------------------------------------------------------------------------------------------------=--------------- <br /> Remodeling and/or repairing {describe):--------------------- ----------------- ------------------------------- --------------------- ------------------------ -------------------------------- <br /> -------------------- -------------------- ------------------------------------------------------------ <br /> ---------------------------I----------------------------------------------------- ------------------------- <br /> - - ----------------------------------------------------------------------------- --------- -------------------------------------------------------------------------------------­ ---------------------------------------------- <br /> ------------------------------------r--------------------------------------------------------------------------------------------------------------------------L---------------------------------------------- -- <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 rule and regulations of the S caqui 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 /> +0110EPARTIVIENT USE ONLY <br /> APPLICATION ACCEPTED BY------- ------- ---- ------------------ ---------------------------------------- DATE------------------------- <br /> -------------- -------------- <br /> REVIEWEDBY-----------------------=-_------------------------------------------------------------------------------------------- ----- DATE-----------------------------------------------------:------ <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DXTE----------------------------------------------:----------------- <br /> Alterationsand/or recommendations:---------------- ------------------------------------------------------------------------*-------------------------------------- ----------------- <br /> - <br /> ------------------------------------------------- ---------------------------------- ----------------­--------------------------------- ------------------------------ --------------- ------------------------------------- <br /> -------------------------------------:------ ---------- ------------------------- ------------- ------ ------------------- ------ ------ <br /> ----------------------7---------------- ---- <br /> ------------- -------- -------------- ---------------------- - -- -- ------------------------------- --- ------------------------------------------------ ----------------------------------------------------- <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 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br />