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APPLICATION FOR SANITATION PERMIT Permit No.-;.4--- <br /> (Complete <br /> o.—."[___(Complete in Duplicate) 3— <br /> } <br /> Date Issued e�_'--r-_.jr...--•_--� <br /> C)- , —_t -ZS <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and inst Il tF�e work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS, AND LOCATIONS <br /> : --� - = <br /> Owner's Nam 1---- --------- --- - ------------- Ph+o <br /> ne-------------- -------------------- <br /> Address--- <br /> -------------------Address--- ------- � ( ----------------- <br /> Contractor's Name------- -- --r---- --_- --e-------------------------------------------------------------------------------------------------------- Phone---------------------------------__ <br /> Installation will serve: Residence �partmenf House ❑ Commercial ❑ Trailer Court ❑ Mofel ❑ Other ❑ <br /> Number of living units: ___/ Number of bedrooms ___.::� Number of baths ___1_ Lot size .f_.S__C—___"_______________ <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 lay ❑ Adobe❑ Hardpan J <br /> Previous Application Made: Yes [❑ No New Construction: Yes ❑ No.L,— yam <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> i (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 /> - ``,, - ----------= <br /> No. of com artments_-__------ ___Size X `!' x$-: Li uid depth______-V_______________Ca acit /4�C� <br /> DisposalField; Distance from nearest well______^_____.Distance from foundation__,_�2_v_______Distance to nearer lot line------ <br /> J <br /> Number of lines__________-- Length of each line___ <br /> : g Width of trent�? --:., <br /> Type of filter mate rial�+�__________Depth of filter material____--------------Total length-------------------------------------- 4 <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line____________W; <br /> ❑ Number of pits---------- -----------Lining material-----------------------Size: Diameter.----------------------Depth---------------------------------L <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material_________---_____________----------_-- <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well __----------------- - 5zistance from nearest building <br /> ❑ Distance fo nearest lot line- ------------------------------------ ------- ------------------------------------=------------------------------A -• <br /> Remodeling and/or repairing (describe) ` ' ! f`tCd' - --- --- ---- ---------- �T <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, Stat laws, and rules/anregulations of the San Joaquin Local Health District. <br /> (Signed) '' - ---- -------- '-----------------------------------------------------------------------------------=----------(Owner and/or Contractor) <br /> BY� --------------------=-------- -------------------------------------------------- ----------------(Title)------------:---------------- <br /> ----------------------- ---------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY------- ---- ------------------------------------------- ---------------------------------------- DATE---- ------------ ------ - ----------- <br /> 1 REVIEWED BY-------------------=-------- ------------------- DATE-------------------- <br /> BUILDING PERMIT ISSUED-------------------------------------=--------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------------- •---------------------- <br /> p ----------------------------------------------------•------------------ ------------------ ---------------------------------------------------------------------------------I-------------------------------- <br /> --------------------------------------------------- - - -------------------------------------------------- ----------------------------- <br /> --------------- •---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY: ? / -------------------- Date---'`--7-~-- --,�------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES---9---2M 8-51 Revised W-2100 <br />