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APPLICATION FOR SANITATION PERMIT Permit No. r ...... <br /> (Complete in Duplicate) <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 Ord•s nce No. 549. <br /> JOB ADDRESS AND LOCATION-- ----- --- <br /> ' ----------------•------------ <br /> P1?�L. <br /> 41e777�ne <br /> -------------- --------------------- <br /> Owner s Name---- ----- - -- --- --- -------- ------- - - - <br /> Address__ . pp <br /> - .Q = ---------------------------------------------------------------------------------------------------------------- <br /> Contractor's Name---------------------- --------------- -------•------------------------------------- Phone--------------------------•------- <br /> - - - -- - ------------------------- <br /> Installation will serve: Residence ❑ Ap ment House ❑ Commercial Tr filer CFsdi <br /> rt I tel Other ❑ <br /> Number of living units: _"_' Number of bedrooms _-----: Number of baths oze --- 4�fa <br /> Water Supply: Public system ❑ Community system ❑ Private k Depth to Water Table __,�4 ft. ff <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 /> SeptiTa Distance from nearest well------..-__-----Distance from foundation-------------------.Material_____------_,_-------.____------- \� <br /> No. of compartments--------------------------Size------ -----------:--------- ---Liquid depth--------------------------Capacity----------------------- <br /> �1 <br /> sposal F,ieild Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line---------.------- <br /> Number o� fines ----Length of each line------------------------------Width of trench--------------------------------•-- <br /> r Type of filter material-------------------------Depth of filter material--------------- ------Total length------------------------------ <br /> Seepage Pit: Distance to nearest well----------- Distance from foundation--------------------Distance to nearest lot line-------.------- <br /> .- <br /> ❑ Number of pits._------------------Lining m tenial--------------------- Size: Diameter------------------- ---Depth--------------------------- ----- <br /> Cesspool:F Distance from neares w II - � istance from found tion----)�------ Lining material _.--------.---- <br /> Size: Diameter-----------�} - Depth---------� = Liquid Capacity-: ` Q -----gals. <br /> Privy: Distance from neares �rrell-------------------------------------------------Distance from nearest building----------------------------------------` <br /> ❑ Distance to nearest lot line-------------- ------------------------------- -------------- ------------------------ ---------------------------------------- -- ---------- t+►� <br /> -------- <br /> Remodeling ' ! _r <br /> • �.wa.- LA 'S- _ ,t. � <br /> and or repairin (descn e]:-- -�-------- --- f /ll <br /> �a --------------------- - - <br /> - ------ -------- <br /> -0 <br /> -- <br /> --- - - - -- -- --- -- - --• -- -{//-yam - - ---- <br /> -0----------- •---- - -------- -- --- ---- --_-- -- - <br /> I hereby, cer ify that I have prepared this application and that the work will be done in a�ri et ar , <br /> ordinances, State laws, and rules and reg4ilations of the San J quin Local Health District. <br /> {Signed}----------- - -! ------------------------ -------- (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 <br /> APPLICATIONACCEPTED BY------------------------------------------------------------------------------------------------- DATE (-- <br /> REVIEWEDBY---------------------------------------------------------- DATE-------- - ------------- <br /> BUILDINGPERMIT ISSUED----------------------- ------------------------------- --------- DATE--------- -------------------------------•---•- <br /> K� ---------------------------------------------------------------------------------11------------------- <br /> Alterations and/or recommendations-------------------------- <br /> ----------------- <br /> --------------==--------------------------------------------------------------------------------------------------------------- <br /> x <br /> ---- - -- ---- <br /> ------------------------------------------------------------ <br /> FINALi 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 10-52 Revised W-2100 <br />