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1 ' r APPLICATION FOR SANITATION PERMIT 1 " • <br /> e';m- a o. 3--3 *�•- <br /> , - <br /> r (Complete in Duplicate) <br /> Date Issued ---- ----- ------ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to con truct and install the work herein described. <br /> This application is made:•in.eompliance with County Ordinance o. 549. ` - <br /> J - = j <br /> JOB ADDRESS AND OCAT N...:- ._ %-- _= -- ---------------------- <br /> Owner s Name ' _-. Phone ={---�- <br /> O <br /> Address .moi.. ... r -----•----------------- ---------- <br /> Contractor's Name = 1 �� - {--- --- ------ ,. = <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ . Other ❑ <br /> Number of living units: t_/"___ Number of bedrooms __ Number of baths Lot size ________________ <br /> Water Supply: Public system ❑ Community systems❑, Private Depth to Water Table 4�ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel 0 Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�Hardpan E]Previous Application Made: Yes [-] No New Construction: Yes [INo�! \\ s <br /> F TYPE OF•INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_________________Distance from fou'ndation----_------------Material_____._-______.-_.__.___________.__:_.- ----- <br /> . <br /> y C� No. of compartments--------------------------Size_----•--------------------------Liqu cldepth--------------------------Capacity----------------------�7�i <br /> Disposal FieldV Distance from nearest well-----------------.Distance from foundation--------------------Distance to nearest lot line-------------- <br /> I <br /> Number of lines-------------------------- ------Length of each line--------'r-----------------.Width of <br /> t r <br /> � pits <br /> - --� french-------------------F------- <br /> ----�----- <br /> �- <br /> Ypoflematerial <br /> pth of filter material_____________ Total ------------------------- <br /> S <br /> _.___-_ __.______._. <br /> Snearee ae Pit: Distaetoestwell_��D---.-._._DStante fm f dati ______/_.Distance to nearest lot line__ __ ----- <br /> f <br /> Number of pits__-__-�__ -- - ---Lining materraSize: Dia ter. � Dept'n- <br /> ; 1�!------- -�Cesspool: Distance from nearest well------------------Distance from foundation---------- ---------Lining�rnaferial_------------------------------- <br /> ❑ Size: Diameter----------------------- -------------De th--------------------- --- ---- --------Li Liquid Capacity 9al� <br /> 1 <br /> Priv Distance from nearest well-_-._:'______________________ - ..__-_-- <br /> Privy: _________ ____ ___Distance from nearest build_ing--_.-_.___._.________._.__._____. 4 <br /> ❑ Distance to nearest lot line_______-I <br /> Remodeling and/or repairing (describe)-------------- -- ---_'_------------------------------------------------------- ` <br /> -------------------------------------------------------------------------------- ----------------------------- ---------•------------------------------------------------------------------------------------------- <br /> s <br /> ------•--- -------------------------------•---_-------•------------------•---------------------------------------------------------------=----------------------------•----.. -. 1 <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, 5ru s and eguia+ions of the San Joaquin Local Health District.(Signed)------------------- - - - ---------------------------------------------------------------------- ------ -(Owner and/oRCohtractor) <br /> By: {Title} rPlot len, showin size ocation of s stem in relation to wells, buildin s, etc., can be aced on reverse sidef <br /> { P g Y g P } <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _..-- --------------------------------------- --- ------ DATE�---------------------------------------------------- <br /> REVIEWED BY-------------------------- DATE---- ---------------------------------------------- <br /> BUILDING PERMIT ISSUED------------------------ --------------•----------------------------------------- DATE-------- <br />, -------------- ------ ------------------ <br /> I Alterations and/or recommendations: -----------•--•------- ------•-- ---------------- -----•------------- <br /> I—!-----------------• -------•-------------------------------------------------------------------------------------------------------------------------I----------•------------------------------------•----------- -' <br /> --------------------------------- l �- <br /> -------------------- ------------ -------------------------------------------------- --------------------- •--------------- ------------------------------­f <br /> -------------------------------------- -------------------------------•-----} -- --------------------------- ------------------------------------------------- <br /> FINAL INSPECTION BY----------------- --- ----- - ------------------------ --- Date........ _. 3 <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 1D-52•-R6-vised W-2100! `� <br />