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FOR OFFICE USS: <br /> APPLICATION FOR SANITATION PERMIT Permit No. .... <br /> --------------------------------------------------------- (Complete in Duplicate) Date Issued ._....?! b <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 Ordinan e No. 549. <br /> JOBADDRESS AND ATION--------:_30 --------------------------------------------- -- •-•------------------ ---------- <br /> q g <br /> Owner's Name-------- --- . •-------------- <br /> Phone <br /> Address---- ---------------_----`J� . .....- ------ -----------------------------------------------------------------------...... ------------------------- <br /> ----------- <br /> ----------------------- Phone��?Name..- �fi ' ----- --------- --------•--------------•-------------------- Phone,, . <br /> Installation will serve: Residence ( Apartment House ❑ Commercial E] Trailer Court E] Motel E] Other El/ i i <br /> Number of living units: ---/ Number of bedrooms .-� Number of baths Z__ Lot size .--_S57XS---15�---------•------------•--- <br /> Water Supply: Public system Community system [I Private ❑ Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ <br /> Previous Application Made: (If yes,date----------------_--l No ❑ New Construction: Yes ❑ No [ FHA/VA: Yes [I No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) <br /> nk:. Distance from nearest well----------- _.-Distance from foundation-------------------Material-------------------------------------._----_----. <br /> No. of compartments----------------------=•--Size---------------------------- ---Liquid depth--••---------------------Capacity--------------------- <br /> i <br /> Disposal F Id: Distance from nearest well{ 14-._ .-Distance from foundation.../.f1----_._.._Distance to nearest lot line..,.? <br /> Number of lines------ ----- --- ---- Length of each line_-- . ---- --------Width of trench------- - ........ Q <br /> Type of filter material__S_- 9 --Depth of filter material....../9----------Total length-------------rte--------------------. `n <br /> Seepage Pit: Distance to nearest we11�Zod��-___Distance m undation___�lI__�-__--.Dista-It to nearest lot line_---�-•- I.- <br /> Number of pits-----/---------------Lining material-- ---Size: Diameter------33.----------Depth------12--�--------------- --.-c <br /> Cesspool: Distance from.nearest well---------------..Distance from foundation---------------------.Lining material_-..----.----_._---.-----__.-------_. <br /> TD:iameter- = ::_.:_:. .Depth =�' �". -` -Liquid`CapacitY-- --------------•------x--gals. <br /> Priv❑ ' Distance from nearest well----:_.-_-._._._____---------------------------Distance from nearest building--------------------------------------- <br /> Y . ,- , <br /> ❑ Distance to nearest lot line.-...--------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):--------------•--------------------------------------.----------------------- --------•-••--------•----•-----•----------------------------------- <br /> f <br /> 1-hereby ce ' y t --------------------•--------- --------••----------------•-------------------------•-------•------------------------------------------------------- <br /> r hat I have pr ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Sta w , d ules n regulaflo of t e n Joaquin Local Health District. - <br /> (Signed)------------- ------- _ <br /> + - ---------------------------------- Owner and/or Contractor) <br /> By:----------------------------------------------------------- <br /> --- -- ------- -------- -•----------------- (Ti+1e) ----------_---------------- --------- ----- <br /> o (Plot plan, showing size of lot, location of Sys em in relation to w , buildings, etc., can be placed an reverse side). <br /> 4 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- -- ---- ----- DATE . 1 <br /> REVIEWEDBY---------------------------------- --------------- -------------------------------------------------------------------------- DATE------------------------- -------•----•-------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------ --------------------------------..--------•---•----- <br /> Alterationsand/or recommendations-----=------------------------- ------------------------------------------------•--------------------------------------••--•----•---------------------------._.. <br /> ------------ ---------------------------------------------------------- -----------•----------------------.•----------•-----------------------------------•-------------------- <br /> -------------------------------------------------------------------------------------I--------------------- -----------------------------------------------­­ <br /> ----------------------------------------------------- <br /> --------------- <br /> •-•---•---• - - ----- ---------•--------- --------------------------------------------------.------------------------------------------------------------------------- <br /> ----- <br /> FINAL INSPECTION BYc. ate--------------- --------- - ----- -------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 114 Sycamore Street 20S West 4th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E9-9 RE�/�BE�9.99 F.P.G9.SM 6-69 <br />