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APPLICATION FOR SANITATION PERMIT Permit No.,-:L2-s7----- <br /> (Complete in Duplicate) Date Issued <br /> San Joaquin Local Health District for permit to construct and install the work herein described. i <br /> Application is hereby made #o the Sa q p , <br /> This application is made in compliance with County Ordinance No. S49. � - <br /> JOB ADDRESS AND LO ATI N-___ -- :- ------ ------ - - ------------------------ <br /> ---------------------- - - <br /> - - ------------------ ---- - - ------- ---------- <br /> --------- - <br /> Owner's Name + -------- Phone <br /> Address ,+ /- - ---------------------------------------- --------------------•------------------------------------------------------ <br /> Contractor's Name------------------ ----------------------- Phone---------------------------------- <br /> Installation will serve: Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motels❑ Other ❑ <br /> Number of living units: _�-_- Number of bedrooms __KNumber of baths ---L-- Lot size -------_--1-Yk- } -- -= --•- <br /> Water Supply: Public system ElCommunity system E] Private Depth to Water Table __ _ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ Nox New Construction: Yes e No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted-if-public sewer is available within 200 feet.) .'! <br /> Se tic ank: Distance from nearest well__��d_--_Distance from foundation____ ___ _______Mafer' I j___ ------- <br /> No. of compartments--------_--'7C'"-___Size_ _ Liquid depth--- <br /> DisposalField: Distance from nearest ellDistance from foundation_____ -___ _ Distance to nearest to i <br /> Length of each line______ // <br /> Number of lines--_________--------_______ Q ___ __ Width of trench_______ <br /> ��,, ff 1,---.Width <br /> length ----------------- "►.. <br /> Type of filter material---- V1!1 __-Depth of filter material____ _ g AP-0 <br /> Pit: Distance to nearest well-------------------__Distance from foundation--------------------Distance to nearest lot line_-_--------.___-- <br /> [] Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------------- F <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-----_--------_-----Lining material---------------------------------- <br /> Size: <br /> _-.--__-_---.- _--_--___--_._Size: Diameter--------------------------------------Depth----------------------------- ----- ------------Liquid Capacity-----------------------------gals. <br /> Privy: Distance from nearest well______ ________ -------------------------------Distance from nearest building--_________._______.___________-___ <br /> Al <br /> ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------�---------- v, <br /> Remodelin and/or pairing (describe):___ ...... <br /> --- - " <br /> -- - ---------=. ............ j - - -------------- ----- <br /> ----t7 vd- <br /> ------------ ------ <br /> 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. <br /> {Signed} = - ------------------------------------------ ------------------------ -----------------------------(Owner and/or Contractor) <br /> By:......:.------------------------ <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 <br /> APPLICATIONACCEPTED BY--------------------------------------- -------------------------------------------------------- DATE------------------------ <br /> 5- ................. <br /> REVIEWEDBY--------------------------------------------- -- ------ ---- -- ---------- ------------------------------------------- DATE------ �% ------- <br /> DATE-- �__ �-- - ------- <br /> BUILDINGPERMIT ISSUED------------------------------ --- -- -- - - ------------------------------------------ --------------------------- <br /> Alterationsand/or recommendations:------------- - ----------------- -------------------------------------------------------------•----------------------------------------------------•--- <br /> ------------------ �---r- --- ---------- -- --------------------------------------------------- -- <br /> '' '3----------- -------------------------------------------------------•-------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------- ---------------------------------------------------- ------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY------------------- -______ ___.-_ -. ---- <br /> Date .- `� --s~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 /> LS-9-2M 5-51 Revised W-2100 <br />