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f FOR OFFICE USE: <br /> ----------- ----------------- <br /> ----------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. .../ �__�: <br /> -------------- 11 . 1 <br /> ----------------- ---------------------------------------- (Complete in Duplicate) 3 d <br /> - 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 /> 1 t <br /> JOB ADDRESS AfN'D LO ION ��' ;-- '----�1/ 6�f? <br /> Owner's Name----W p y L Phone-------------------------------- <br /> ----------------- <br /> Address <br /> ---------------------------- <br /> Ad d ress....:. ` ----------------- <br /> Contractor's Name--------•--------- . = • ------------------------------- Phone----------------------------------- <br /> Contractor's <br /> will serve- Residence ❑ Apartment House ❑ Commercial [ "frailer Court 0. Motel ❑ Other ❑ <br /> A.: <br /> F Number of living units:'"ii-n,Number of bedrooms --"'^ Number of baths _-�,, Lot size J_�---------------------------- <br /> Wafer Supply: Public system Pertommunity system ❑ Private ❑ Depth to Wafter Table _xf-ft. <br /> Character of soil to.a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe g?"14ardpan ❑ <br /> Previous Application Made: (if yes!date--------------------_I No 'New Construction: Yes 9�/' o ❑ FHA/VA: Yes ❑ No �•+ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i <br /> r <br /> Septic Tank: Distance from/nearest well .` �'�__--Distance tom fpui dation..�Q__-Yk---.Material---cr-G-- * . <br /> No. of com artments----- ---------------SizO_ ,�M-- quid dep}�----- - ------------.Capacity.fr�.r0 �. <br /> -,p i y <br /> t <br /> Disposal Field: Distance from nearest <br /> .` well. -��' '--.-Distance from foundation------— -- ------Distance to nearest lot line__.--._.--. <br /> [ Number of lines-_X-- -_r_-- .---_-_Length of each line D-�-_- .. p Width of #rench---Q-_ --�_oe----------------- Q <br /> Type of filter material _/ Q_ Depth of filter material__ __-_�---Total length_-------a---Q......------...... .- ,.._ <br /> Seepage Pit: Distance to nearest <br /> well "- ----__Distance fr m foun_d. ation__.' �__.--. Distance to nearest lot lin _�----------.e -Number of pits:-----Z----------Lining material_� _9: & Size: Diameter---� -- Depth--__,Zj---- --- -----_-.- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------i'_----------Lining material--------.---_-.-----__-_----_---__---. <br /> Size: Diameter- ------------------------------------De th--------------------- -----------------------------Liquid Capacity gals. <br /> Privy: Distance from nearest well----------------------------------------------------Distance from nearest building:--------------_----__-___--_----.--_--... .� <br /> ❑ Distance-to nearest lot line---------------------------- -----------------------------------•----- <br /> � <br /> •------ --,.� -------- <br /> Remodeling and/or repairing �clescr _-------.-._••--•.--•---------i�e):_---- - ✓-_-.. <br /> i ... - < <br /> --------------- <br /> .� <br /> --------------------------------------------------- <br /> ------------------------------------------- <br /> --------- ------ ------------------------------------- --- - -. <br /> -------- .----._-..---------------e---�-•1 <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 regulations of the San Joaquin Local Health District. <br /> (Signed} �/or Contractorl <br /> -------- -- --- - - <br /> { r <br /> BY:-------------------------------------------------------------- -- -----------------------(Title) <br /> (Plot plan, showing size of lot, location of sysfe inrelation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- - r-� 2G�� DATE l <br /> -- <br /> ---------- <br /> REVIEWEDBY---------------------------------------------------------- -------------- --=-------------------------------------------- DATE-------•-----------•--------------------------------------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------------------- -------------------------- DATE------------------------------------------------------•--•- <br /> Alteration, and/or recommendations---------------- ---------------------------------•---•---------------------•--------....................•---•---- - • ..-. .------------------------- <br /> 7` � ?;r _ _�. �lr t --- ------------------------- <br /> -- - - --- --- <br /> ------ ------------ <br /> ------------ <br /> 7_7 <br /> INSPECTION BY:---- � Date----- �f ` (�{ -------------------------------------------- <br /> -- ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 5.k 300 West oak Street_ 'N,\ 124 Sycamore Street 285 Wast 91h Street <br /> t <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> Er-9 REVISED 0.59 F.P.Ca.2M 6-611 <br /> i r <br />