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FOR OFFICE USE: <br /> --------------------- ----------- ------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------------------------------------------------------ -- <br /> "' `' (Complete in Duplicate <br /> 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 /> l��� � <br /> This application is made in compliance with County Ordinance No. 549, <br /> ----- <br /> JOB ADDRESS AN - <br /> LOCATION-.ol- �-- -4. - ---- �!- -'o <br /> Owner's Name----- - ---- �-- --- ' --------------- --------------.... Phone-- -------- ------_------------ <br /> -- -------------------- --- <br /> �- _Address------------------------ ----• ----- -- -------------------------------------------- - -------------------------------------------------------------- -----------....-----� <br /> Contractor's Name--_ -C Phoneri ,e� <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _/Community <br /> mber of bedrooms ---- Number of baths _-..---_ Lot size _ -. `��--------------------- <br /> Water Supply: Publics stem system Private Depth to Water Table -------- ft. <br /> PP Y� Y Y ❑ ❑ p <br /> Character of soil to a depth of 3 feet:'I Sand ❑ Gravel ❑ Sa y Loam lay Loam lay ❑ Adobe❑ Hardpan C]Previous Application Made: {lf yes,date---------------- ---1 No New Construction: Yes No ❑ 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.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation------------.------Material------.-------------.-.-------------------.--.--. <br /> No. of compartments----- --------------------Size-----I­-----------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well. ---------------Distance from foundation--------------------Distance to nearest lot line------------_---. <br /> ❑ Number of lines-----------------------------------Length of each line----------------------------..Width of trench----------------•-.---------------- <br /> Type of filter material-------------------------Depth of filter material ---._-----------------Total length------------------------------------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation----_-_-----..--_--.Distance to nearest lot line----------------- <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation----- --------------Lining material-- -.- - _.-. <br /> Size: Diameter 1b x Depth ------------------- Liquid Capacity 1 � gals. <br /> Privy: Distance from nearest well --------------------------_--_---.---...------Distance from nearest building.----...------______-----------..-.----- <br /> ❑ Distance to nearest lot line------------------------------- ----------------------------------------•-------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------ ---------------------------------------------------------------------------------------•------------•---------•---------------------- ----------------------------------------- - ----- <br /> ----- -------------------------------------------=------------------------------------------------------------------------------------------------------------------------ ----------------------- ----------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County a <br /> ordinarii State-la vyss _and riles and regulations of the San Joaquin ocal Health District. <br /> (Signed �-----t&_'-r : « --- -------------------------------------------------•----------------- Owner and/or Contrac#or� <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--------- --------- - lD(---------------------------------------------- DATE f�' d g <br /> REVIEWEDBY--------------------------------------- ---------------------------------------------------------------------------------.-.- DATE----- ------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-------•--------------------------------------------------------------------------------------------. DATE----------------------------------------------------------- <br /> Alterationsand/or recommendations:--'------------- ------------------------------ --------------------------------------- ----------------•--------- ------------------•-------- ---------------- <br /> ---------------------------------- <br /> ------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ---------- ------------------- ---------------------------------- - --------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------- ------------------- - ---------------------------------------------- ---------- ----------------------- ----------- ------------------------------------- <br /> ------------ - -- - ----------------------------- ---------------- - ------------------------------------------------------- ---------------------------- ------ --- - ------ ------------------------- <br /> \J <br /> ---------------------- - <br /> \J <br /> FINAL INSPECTION BY:. - -----------......... Date gf--- <br /> ---------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy, California <br /> F.P.CO. <br /> i � <br />