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-� FOR OFF1C� USE: <br /> y - G <br /> � � -L <br /> ° Permit No. -- /- <br /> --------------- APPLICATION FOR SANITATION PERMIT <br /> - - ---- ---- <br /> d <br /> . . (Complete in Duplicate) Date issued <br /> ------------------------- ---------------- <br /> This Permit Ex iras l Year From Date Issued <br /> Application a the San Joaquin Loca <br /> a <br /> tion is hereby made tl Health Distrriic for a permit to construct and install the work herein describe . <br /> This application is made in compliance with County Ordinance <br />! ---------•------•--------------------------------------------------------------------------------------- <br /> JOB <br /> --- --------------------------------------------- <br /> i JOB ADDRESS AND LOCATION."" J`�-------- Phone.--...-•-----. .----•-----•--------- <br /> ° ` <br /> -------------- <br /> Owner s Name."" <br /> --- -----••----- <br /> ---•------ <br /> Address----..-_ Phone............. <br /> i <br /> Contractor's Name..-- --- .��'-"-----•----••----••-----------•-----•-----•-----•- - •- - --•- ----------------------------------------------------- <br /> -�- Motel ❑ Other ❑ <br /> Installation will serve: Residence eApartmnt House ❑ Commercial ❑ Trailer Court <br /> Number of living units: ._"." Number of bedrooms ."�. Number of baths ---I.. Lot size -_--- - / " """ <br /> N ��t. � <br /> Private �epth To Water Table -- ardpan ❑ <br /> Water Supply: Public system ❑ Community system ❑ y Cla Loam ❑ C1ay ❑ Adobe[�� <br /> 11' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam ❑ Y FHA/VA� Yes ❑ No <br /> Noe New Construction: Yes [ No ❑ <br /> previous Application Made: (if yes,date-------- ---- 1- No LA <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Distance from nearest well-_-"_". Distance from foundation--------------------Material__-----.-Capacity---------------------•- <br /> I Septi nk -- -----Size-------•------------------------ 9 R <br /> No. of compartments----------------- <br /> Dis osa ield✓ Distance from nearest well_.- ------Diance ofreach I sedation------ -------:'-Widthcoftfrenchest lot line----------------- <br /> p ��� <br /> ❑ Number of lines-----------------------------------Length <br /> Type of filter Depthmaterial-----------------------• of filter material--------------------•-.Total length---•--•---•-----•------•------�---•-•-• <br /> well"_ ,��-A------- Di ante from foundation... " --1----.Distance to nearest lot ine .±:5.- --- <br /> Distance to nearest ----.Depth-.--. --•-------------- <br /> Seepa 'Pit: <br /> Number of pits-------- -•---. Lining material G-L-x_Size: Diameter--3--------- <br /> als. <br /> Distance from nearest well".---------------Distance from foundation-----------------" Liinuid Capacitying e ------------------------------------- <br /> Cesspool: g <br /> ---Depth--------------------------------------------------- q -------- --••------------- <br /> ❑ Size: Diameter------'---- ---------------�---•- <br /> 4 � Distance from nearest building"""._"---------------••-••---•------___._. <br /> Privy: Distance from nearest well"-_"".----------- <br /> ❑ ------------------- <br /> ---------------------------------------------------- <br /> Distance <br /> -------•------•-------•---•----------••---- <br /> Distance to nearest lot 'sne"--"""-----".__._"-"_- , . <br /> -------- --------•--------"------•---------•-----•---•---------.----- <br /> Remodeling and/or repairing (describe:"----------------- --- ---- <br /> ° --- ---------- <br /> '----------------'"----------'---------------------"--•-----••---•---•-- <br /> _--•"""""_.__._"_--_-_-•--------------•--•--------•----_--_-----_-----_--•---.--••__..---_------------------­----------- <br /> ---------------- <br /> ----_--__----_--_••_-----••-._-."""-._"-.".'"-- <br /> done <br /> 1 hereby certify that I have prepareddthisap olf tton o Safi Joaquin that hLocal kHeall heDistr ctn accordance with San Joaquin County <br /> ordinances, State laws, and rule aregulations <br /> _".-""-"_""_.""- "--."......(Owner and/or Contractor) <br /> --------------- <br /> ( 'gSi ned <br /> ) -- -------(rtlel <br /> BY:------------------------------------------------------- - <br /> - <br /> (Plot plan, showing size of lot, location of system in relation to /eibuildings, etc., can be placed on reverse side. <br /> I FOR DEPARTMENT USE ONLY <br /> = <br /> APPLICATION ACCEPTED BY 0.�----- -------------------------------------------- DATE._"I -...-•-�--� <br /> -- DA <br /> REVIEWED BY_----�--•------------------•------------ . - ----- - <br /> --•---------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------- -- --•------------- <br /> --.---------� �- <br /> � - - ! ........ -_---------- <br /> Alterations and or reco ren atiops:"__._".""--".--". T " <br /> - <br /> D --- <br /> — — --------------------------- <br /> FINAL INSPECTION BY:....-"- ".- <br /> --- ­------- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street <br /> 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,callforrila <br /> manteca,-Cailfornio Tracy,California <br /> t � <br /> ES 9 REVISED 8.59 2M 5.62.ATLAS : <br />