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FOR OFFICE USE: <br /> - � � Permit No. <br /> - ----------------- - ---------------- <br /> - -" APPLICATION FOR SANITATION PERMIT <br /> ---------------- - -------------------------------- ,1 -- <br /> (Complete in Duplicate) -�"_"_ __ <br /> ---------- -------------------- ----- Date Issued <br /> This-Permit;ExTres 1 Year From Date Issued <br /> Application is hereby made fo ttie San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> r This application is.made in compliance with County Ordinance No. 549. <br /> t - <br /> _ ----------------------------------------------------------- <br /> JOB <br /> I ADDRESS AND LOCATION-.'_-"-3-1--- ---------- <br /> --- <br /> -----------1. Phone-----•-----•-----------•------------ <br /> Owner's Name---------- 4 r ------ <br /> - ._f <br /> - <br /> 01, <br /> ' <br /> - �JY - --------------------- ---- <br /> Address-----.•------ - - ---- Phone.' -, 3Z <br /> Contractor's Name--------- <br /> - -- <br /> Installation will serve: Residence [apartment House ❑ Commercial ❑ Trailer Court [:] Motel C] Other C3 <br /> 0j <br /> Number of living units: "./_ Numb-er of bedrooms _9'" Number of baths -" -" Lot size "-_"Sd - '� <br /> Water Supply: Public system [[Community. system El Private ❑ Depth to Water Table o ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel 171Sandy Loam ❑ Clay Loam ❑ Clay [3 Adobe ' Hardpan ❑ <br /> - No El <br /> Previous Application Made: (If yes,date--------- ---------) No R New Construction: Yes El No 'FHA/VA: Yes ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> i (No septic tank or cesspool permitted if.public sewer is available within 200 feet.) f <br /> ,t3rnr _.."-"""__"-".._---".".._-""_"."_-,-"_"_____".._ <br /> � i <br /> I <br /> Septic Tank. Distance Distaricefro� nearest well_.".".__--""__--"Distance from foundaton_"""_"."-_"-_""....Matena . <br /> ❑ JIMr✓S77itlf' No..of compartments----------------. <br /> --------Size--------------------------------Liquid depth------------------------ -Capacity----------------------- <br /> Disposal Field:K. Distance from,nearesf well-----------------Distance from foundation.------.--.-.------.Distance to nearest lot line----------------- <br /> ❑ FW 57pf Number of lines=------------ --------- --------Length of each line-----------------------------Width of trench : W <br /> t, Type of filter material"""".___""".-"..""___"-.Depth of filter material--"_..__-"__-___--/.__Tota length------------------------------------------ <br /> t, <br /> " " .-_ ""_"_""" ." """ � <br /> 0 <br /> AA,, ��"_.""- Distance to nearest lot line//----- <br /> Seepage Pit: . " Distance to nearest wellPl�,O)Y-'�--Distane om foundation_______-- ,! <br /> Number of pits-------------------Lining material-�� ----Size: Diameter----- -, ----------Depth-----02 ---------------- <br /> Cesspool: (Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- <br /> Size . <br /> ❑ :Diameter- -."_._."..-.__"-"_____-". _ - ---- <br /> ------.Depth----------------------------------- -------------Liquid Capacity_-------------------------gals. ' <br /> - - <br /> Privy: Distance from nearest well----------------------------------------------...Distance from nearest building------------------------------------------ <br /> ❑ ------------------------ <br /> Distance to nearest G+ line- --- - ---- -------- ----------- - ------------------------------------- ------=-------------------- <br /> � t <br /> Remodeling and/or repairing (describe)-------- -------- ------------ --------------------------------------------------------------•--- �-------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------- ; <br /> r ---------------------------- ---- <br /> --------- <br /> -: ' --------------------------------------------------- <br /> 1 hereby certify fhat 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 r gulations of the San Joaquin Local Health District. <br /> �^.�... - ---- ---- (Owner and/or Contractor) <br /> Stned - - --------------- - ---- ----- --------- <br /> I }, <br /> By=--------------------------- = (Title)- / t - <br /> (Plot plan, showing size of lot, location of syst in relation to wells, buildings, etc., can be placed reverse side). <br /> ! � t <br /> FOR DEPARTMENT USE N ` <br /> APPLICATION ACCE <br /> yPTED BY-"-_"". ------------- �----- <br /> ""-_ -- ----- <br /> ------- ----- --- ---� t�_ DATE----------- r <br /> " " - - <br /> REVIEWED BY---- -----=----------------- - ---------------------------------=--- -------- ---------- <br /> -- ----------------------- DATE------------------------------------------------------------ <br /> BUILDING PERMIT ISSUED--------------------------------------------------------------------- --- ------ <br /> DATE----------- ------------------------------------------------- <br /> Alteratio anal/or recommendations:__-.----------------------"- <br /> W- -- - __ <br /> t ----------------------------------------------- ------------------------ <br /> - ----------------- -------------------- ------------------ ------- <br /> -- ----------------=-----------:----- - - ------------------- ---- ---- <br /> F <br /> 1 Date- <br /> -------- <br /> ".vl.- ' a� ----------------- <br /> FINAL INSPECTION-.►BY: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> 1601 E.Ha:ellon Ave. 300 West Oak Street' 124 Sycamore Street y 205 West 9th Street <br /> Lodi,California Manteca,California Tracy,California <br /> Stockton,California <br /> r.p.ro. <br /> f <br />