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FOR OFFICE USE: <br /> rt / <br /> -------------- <br /> - -----�{- ------- --- --------------------3_. APPLICATION -FOR SANITATION PERMIT Permit No. <br /> ------ --------------------------- - ------------- (Complete in Duplicate) <br /> -------------------------------------- This Permit Expires 1 Year From Date Issued Data Issued e4?— <br /> - <br /> Application <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. t <br /> JOB ADDRESS D LOCATION--__- - -J---- � ,t,D�g -----_--- - <br /> ------------------------------------------------------------------------------------ <br /> Owner's Name-- J ------------------- --- ------------------ Phone---------------------------------- <br /> Address------------ <br /> ---- <br /> Address----------- � _.. ...1 _ -------'--------------------------•-------------• , <br /> Contractor's Name----------- - - ------ aLl------ - ----------------- Phone......................._-•------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __/__ Number of bedrooms ___ _ Number of baths Z__-_ Lot size .r l -_.-,1.4- ------------------------- <br /> Water Supply: Public.system [Community system ❑ Private ❑ Depth to'Water Table _0"ft <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy,Loam ❑ Clay Loam ❑ Clay ❑ Adobe T­_qardpan ❑ <br /> Previous Application Made: (If yes,date---------._ ______I No [P!New Construction: Yes ❑ No [ `FHA/VA: Yes ❑ No Q_ <br /> TYPE-OF INSTALLATION AND SPECIFICATIONS: l <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> t <br /> Seti -Tank, Distance from nearest well________________Distance from foundation_________________ Material- _ <br /> _______._____- _____-_._______.___..____-____-- <br /> Suc5// No. of compartments Liquid de th--------_---------------1-Ca Capacity p f _ p Y <br /> Disposal Field: Distance from nearest well -._.Distance.from.foundation__fZ_p est lot line-_ _--______ <br /> P _� _____-----Length of each line--- Width cofttreIn h <br /> Number of Irnes________�_ __ ____-_ <br /> Type of filter materiWl A!� Y4_Depth of filter material_.-./ ______..Total length___ 1 __________________________ <br /> Seepage Pit: Distance to nearest well_3_�'____..___Distance fr fou cfation__Z --------Distance to nearest lot line___..______ <br /> ®� Number of pits`____�____ _4JLining material___ .. -OC✓s._-'Size: Diameter____ =, _ _.- Depth <br /> Cesspool: Distance from nearest well_________________Distance from foundation___-___--_-_-------.Lining material__._...__________-_.__-________.___. <br /> ❑ Size: Diameter-1-------------ut---- ------------- Depth---------------------------------------------------Liquid Capacity-- -------------------------gals. <br /> Privy: Distance from nearest weft____________________________________________--_Distance from nearest building__---..______.__________________..__.._. ' <br /> ❑ Distance to nearest lot line ` _ ------ -------------- ------------------------------------------------------------------------------------------------ E <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 " <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. f <br /> ( <br /> (Signed) _.t----------------(�er Contractor) r` <br /> By: ---------- .................... <br /> (Plot plan, showing size of lot, location of system in relati Pfoweflls, buildings, etc., can be paced on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------------- - ----- ---------- ----------------------------------------------- DATE----------A/_ / ------ <br /> REVIEWED <br /> ----REVIEWED BY------------------------- ------ -------------- - ---------- ----- ------ -- ------------------------ <br /> DATE--- ----------------------------------------- <br /> BUILDING PERMIT ISSUED----------- DATE-------------------------------------- -----------------'---- <br /> ; <br /> Alterations and/or recommendations:---------(I -- ------------------•---------•-.• <br /> --- ------------------- -------------------------- --- .._.-. ----- ------------------------------ ----- <br /> ---------------- ------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------- <br /> --- ------------------------------------------------•------------------- - -------­-------------------------------------------- - -------------------- ----------- --------------------- -------------------- r <br /> ----------------- ----- ----- ---------------------------------------------------------•-------- -----------------------•--------------------------------------------------•-------- ------------------- <br /> FINAL INSPECTION BY:----- r'/' Date------------- .......... ------ --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hasellon Ave. 300 West Oak Street, 124 Sycamore Street, 205 West 9tt,Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F.a.co. <br /> �`'� r <br />