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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date issued --- <br /> Applica+ion 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. 544. <br /> JOB ADDRESS AND LOCATION. --- --- ------61-------Fr4-4-on. <br /> Owner's Name--------- ,_ -•-------------------------------- -------------------------------------------- Phone------ ----_----------------------- <br /> Address_---------- <br /> ---••-----------------------Address------------ S- ....... ------------------------------------------------------------------------------••--------------------------------------- <br /> Contractor's Name L - Phone--------------------------•----- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [❑ Motel ❑ Other ❑ <br /> Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ___________________________________________________.____._ <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 ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> is Tank _ <br /> Distance from nearest well_________________Distance from foundation_-____-_____._.._._-Material_ _____________._..___--___________ ______- <br /> �� fSI I PtlNo. of compartments------------------- ----------Size--------------------------------Liquid depth--------------------------Capacity-------------------------- <br /> Disp�l Field: Distance from nearest well.6�____-Distance from foundation----1_Q---------Distance to nearest lot line_____5`f.______ <br /> Number of lines----- gth of each line----�._ _.�_____ __ Width of ---____``�� <br /> Type of filter material of filter material___._._+f._ _ .___7ota1 length________. _�?__b__.___'_______.__-- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation_____-__--...._.___ Distance to nearest lot line_._=--- <br /> __-----.-- <br /> ❑ Number of pits----------------------Lining material-------------------.---Size: Diameter----.-------------.----Dept h--------------------------------- <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining materiaV_._.--------------------------------- <br /> El Size: Diameter--------------------------- ----Depth.- -------------------------------------------------Liquid Capacity--------_------------------gals. � <br /> Privy: Distance from rearest well----___--- ------- ----------------- -'._.-_Distance from nearest building-------------------------- <br /> [] Distance to nearest lot line---------------------------------------------------------------------- <br /> Remo eling ry 0, repairin describe) � -- --- - ------ #!1 p. -,--- -(jrQ. ., -.'• ----._... <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 law , and rule and r gulaions of the San Joaquin Local Health District. <br /> r? <br /> Si ned = -----------------------------------------------------------------------(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 /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- ---- ----------- ---- ------ ------- -- - --------------------------------------------- DATE-------- 1------------------------------------------ <br /> REVIEWEDBY-----.------------------------- ----------------- -------- -------------- ------------------------------------------ DATE------ ----------- <br /> BUILDING PERMIT ISSUED------------- ---- •- -• DATE-•-------------- ------- ---- <br /> Alterations and/or recommendations: - - - ' <br /> ------------------------------------------------------------------------------------------ ------------------------------------------ <br /> ______________________________________________________________________________________________________________________________________________________________________________•-•_______..__-___..-_----._.-________._________ <br /> ______________________________________________________________________________________________________________________________________...______...._._____.._...______.-_._--_____________._._...____._.____•-_-__-_________ <br /> __ _ __ _ _ __ _---------------_______________________ ............_____________._._.__._-.__•-_.-.__.------__.-_-_.-._.__.----.-_..__-._-.._.._._.-__..____.__.____-____..____.___________-_-__-______.__.___._ <br /> FINAL INSPECTION BY:.---.. "6 -- -------- ------------- 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 /> rS-_9 145446 ATwUUD <br />