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FOR OFFISE: <br /> U/` -� �'- <br /> / APPLICATION FOR SANITATION PERMIT Permit No. .......:................ <br />------ --------------------------------------- <br />----------------------------------------------------- -- (Complete in Duplicate) ICS •--1 �J- i� f <br />--------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> 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 Ordinance No. 549. , <br /> JOB ADDRESS AND LOCATION-N- )3,t �- -cz/ l-------' ••. ,( .. ........... ...................... <br /> Owner's Name " c ------------------------- ----------- <br /> ..........---...-----•--------•----- Phone................................. <br /> Address.--_--------- ' - -------------------------------------------------------------- ---------------•---------•-•------------------------------------------.... <br /> Contractor's Name....... J.t .�------ .._Z" S' -. ..... ......... Phone................................... <br /> Installation will serve: Residence lj}--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ....L Number of bedrooms _4___ Number of baths ___1___ Lot size . _4,c ----------------- <br /> Water Supply: Public system [ICommunity system ElPrivate [A--6epth to Water Table _ ft. <br /> Character of soil to a depth of 3 feet: Sand Ur_­6ravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No EB' New Construction: Yes n- 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 ank: Distance from nearest well_________________Distance from foundation--------------------Material.------------------------------------------------ <br /> �y No. of compartments-------------------- ----Size--------------------------------Liquid depth--------------------------Capacity----------------.--•--- <br /> Dispo ak Fi Distance from nearest well__XO_._____Distance from foundation..A�L______._Distance to nearest lot <br /> Number of lines.._.._______`f ____ Length of each line........57D-------------Width of french_______a_S'---_____________ <br /> Type of filter material... . Depth of filter material-----4.............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 /> El Size: Diameter--------------------- ------Depth_-------------- ---------------------------Liquid Capacity ...........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 /> I hereby certify that I have prepay this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and a ula 'ons of 'the San Joaquin Local Health District. <br /> (Signed) --------------------------------------------------------------------Owner and/or Contractor <br /> By:.....................--- ---• -- -- --- -------- -- ---------------------------------------------------------------(Title)---------------------------------- - <br /> (Plot plan, showing size o , locati of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------- eta- ------------------------------------------------------- DATE--------- _ ----------- <br /> REVIEWEDBY-------------------------- --------------------------------.................. DATE------------------------------------------------------ <br /> BUILDING PERMIT ISSUED---------------------------------------------------------------...................................... DATE------------------------------------------------------------- <br /> Alterations and/or recommendations------------------------------- ----• --- ---------------------------------------------------------------------------------...._.-----------------•-----•---- <br /> --• --------------------------••----------------•---------------------------------------------------------------------•------------------------••---------•------------•-------•---------------------•---•------------- <br /> ............................................................. -- ------- - -------- -------•-----•---- --------•-------------------•------------------------------------------------------------------------- ............ <br /> f <br /> FINAL INSPECTION BY:_...... ' Rate <br /> 0 <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Strut 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E6 9 REVISED 9-59 214 5-61 All As <br />