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APPLICATION FOR SANITATION PERMIT Permit No. .. <br /> t (Complete in Duplicate) ff <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 LO ATION..... 3- ------------ - --- --' -- -- --------------------- ( ----------------------------------------------- <br /> Owner's Name-------- <br /> -- - --•-- �---- -- -• - -- ------ ------------------- ----- Phone--------------------- <br /> -- -,--- -------- ----------------•----- ----------- - ------------------------------------ <br /> Address--....---------- -------------------------------------------------------------------------------- <br /> Contractor's Name---------------------------------------------------------------------------------------------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel q Other <br /> +-� f <br /> Number of living units: �_: Number of bedrooms f Number of baths ____ __ Lot size -- J ___._____.__ <br /> �.._r_..�. . <br /> Water Supply: Public system ❑ 'C!munity system ElPrivatep Depth to Water Table ,31'5 ft. <br /> Character of soil to a depth of'3 feet: Sand ❑ Gravel ❑ Sandy Loam E] Clay Loam ElClay [] Adobe 6< Hardpan C]11F <br /> Previous Application Made, Yes E] No El New Construction: Yes ❑ No ❑ PHA/VA. Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if blifc s er is available within 200 feet.) <br /> t � r <br /> Se tic Ta Distance from °nearest well_ iD stance from foundation- Mateial ----------------- ------ -------- <br /> No. of compartments..___ —--- _,_._Liquid 'depth_____4--____-______._Capacity____ ________________ <br /> _aqI , � ; f <br /> Disposal Field: Distance from nearest well_ _____.Distance fro' at <br /> _(�r�___Distance to nearest lot linj.S- ---_--__. <br /> Number of lines- _--_- - Length of`each line________ _ Width of trench______-___ <br /> € _ �r <br /> Type of filter mate'rial___ ______Depth of filter maferial___ _ -_______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-_------------------------------- rrQ, <br /> Cesspool: Distance from nearest well---_-------------Distance from foundation--------------------Lining material------------------- --_-_-_______ <br /> El Size: Diameter---------------------- ---------------De th----------------------------------------------------Liquid Capacity ---------gals. <br /> Privy: Distance from nearest well------------------------------------- -----------Distance from nearest building_____-________________________________... <br /> ❑ Distance to nearest lot line-------------------------------------------------------------------------- - --------------------------------------------------------------- <br /> ibe :___Rdeling and/or repairing (descr ---_ <br /> --• ----- ------------- ----- --------- - ----------- <br /> .r ii; <br /> - - ---- - --------- -------------------------------- <br /> k-- , a <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, S+at laws, and rules and regulations .of the San Joaquin Local Health District. <br /> Si ned -tGt ____ ____ r —- ______________________ + _____Owner and/or Contractor <br /> By:-----------------------------•---•----.....--------------------------------------------------------- ----------------------------(Title)------------------------------------------------------------. <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY t <br /> APPLICATION ACCEPTED BY------------------------------------------------------- ------------------------------------------ DATE_ <br /> REVIEWED BY------------------------------------------- - ---T__ --------------------- DATE. —BUILDING PERMIT ISSUED-_----------------------- G --------------------- DATE--- `---- <br /> Alterations and/or recommendations:----------- .___ `-� <br /> - --------------------- -----------------------------------------------4-------------------- -- -_-- <br /> ti <br /> -----­-------------------------------------------------- <br /> ---------------------------I-------------------- ----------------------------------------------------------------------------------------------------------------- ---------------------------------------------- <br /> ----------------------------------------------------------- -----------m--------------------------------------------------------------------------------------------i---------------------------------------------------------- <br /> ------------------------------------------------------------------ --- - ------------------------------------------ ----------------- ----- --------------- -- ----------------------------------------------- <br /> FINAL INSPECTION BY:------- --- - - - Date-------- - ----------------------------------------------- <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 , Revised 1-57 F.P.CO. <br />