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FOR OFFICE USE; - <br /> -------------------=----- ---- ---------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. .__ �_ <br /> -------- -- ----------------- ------------------ -------- (Complete in Duplicate) <br /> --.......... This Permit Expires 1 Year From Date Issued Date Issued _V <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 Countyrdinance No. 5.49:. <br /> JOB ADDRESSLOCATION__S � <br /> Owner's Name---- - - ---•-- -- -- -- - -------------------- - ------------- ------ ---- --------------------------- - Phone-----------••-------•--------------- ' <br /> Address-------- �o-------• <br /> - - --- •----------------------- <br /> Contractor's Name---------- - s ---------------------- Phone----------------------------------- <br /> W <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _/..___ Number of bedrooms __'Y_ Number of baths __.�__ Lot size --- <br /> ___ ______------- ------- <br /> Water Supply: Public:system ❑ Community system ❑ Private [?/Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date_:._.................. 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.) i <br /> Septic Tank: Distance from nearest well_________________Distance from foundation__.____________-__.Material---._.__.__ ..____..._________.._.....__-____. O ' <br /> No' of compartments _____Size__-_-.--------------------------Li uid de dep0.......... Capacity.... <br /> _ ❑ pq R ......... ......... <br /> Disposal ed: Distance from nearest well-_414,-_ Distance from foundation___4a__._--__-.Distance to nearest lot line____._____ <br /> Number of lines-----------/--- ------------------Length of each line---- ---------------Width of trench__, -- ----.--------------------- <br /> Type of filter material-------6 A—A-.___Depth of filter material____ /' _Total length Q_�______________ ___________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------1 <br /> ❑ Number of pits.-.)------------------Lining material-----------------------Size: Diameter.----------------------Depth-------------------------------_+. <br /> Cesspool: Distance from nearest well________________Distance from foundation----------------.__.Lining material_______--_-___-_-.-- <br /> Size: iameterf C <br /> - ------------------- ------------- Capacity--------------------- ---gals{ <br /> Priv Distance from nearest well-------------------_----------------- -----......Distance frorr nearest buildin <br /> ❑ Distance to nearest lot line ----------- <br /> ---------------------------- -------------------------- ; <br /> Remodeling and/or repairing (describe)_______________________K ------------ ._ ____ l; <br /> ------------------•-------------------------------------------- ------ ! <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 <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. r <br /> (Signed)--------------- - ----------------------- and/or Contractor) <br /> By:--------- ------------------ ------------------------------------------------(Title)-------------------------------------- ...........------- w <br /> (Plot plan, showing size of lot, location of system in lation fo wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ ---- ----------- ---------------------------------------- DATE_.¢- <br /> 1-7 <br /> REVIEWED BY = - --------- ----------- --------------------------------------------- DATE <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----------------------------------------------------------- <br /> Altera#ions and/or recommendations------- ------ - - -- - ----------------------------------------------------------------------------------------------•-------------------•------------------- <br /> ----------------------------------------- ---------------------- -- ------------------------------------------------- -•--------------------------------------------------------------------------------------------------- <br /> ---------------- --------------------------------------------------•-------------------------- ---- -----------------------------------------------------------_...--------------------------- ------------------------- <br /> { <br /> ------------------------------- ------------•------- ----------------------- ------------------------------------------------- ------------------------------------ ---------------------------- - -• <br /> t <br /> --------------------------------------- - -- ------ ---------------------------------------------------- ------------ ------------------------------------------------------ - ---- ---------------------------I- ------ <br /> •---- ----------- Date <br /> FINAL INSPECTION BY: �'//q'e <br /> -"°�-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 4 U <br /> 1601 E.Ha:elfon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California _ Manteca,California Tracy,Colifornia <br /> 4 <br /> F.a.c o. 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