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APPLICATION FOR SANITATION PERMIT Permit No. _J ____________-- <br /> (Complete in Duplicate) <br /> Date <br /> plica+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. 549. <br /> JOBADDRESS AND LOCATIO -------�L ---------- - --------=-- --- ---.... . . ---------------------------------•--•-•---T------------ <br /> i <br /> Owner's Name--/ r '----- -- - Phone <br /> Address... '- i �� ------------ ------------=--------- Phone s <br /> ------------------------------------------ <br /> f Contractor's Name-------� ---- -- - --------•----•--- ---- ` � <br /> Instalie+ion will serve: Residence [t/Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___V_ Number of bedrooms _Z__ Number of baths -------- Lot size ____________________________________________________________ <br /> { N Y <br /> Water Supply:-Public system �ommunity system 'E] Private ❑ Depth to Water Table�U: ft: <br /> Character of soil to a depth of,3 feet: ISand ❑ Gravel ❑ Sandy Loam:❑� Clay Loam❑ Clay ❑ Adobe 24�-14ardpan ❑ <br /> Previous Application Made: Yes ❑ No P 1 )w Construction: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: v 1 <br /> (No septic tank'or cesspool permitted if public sewer is available within 200 feet:)5. .-•.. <br /> Septic Tank: Distance from nearest well_________________Distance from foundation______._____._'-:___.Material_.______._.._._______________._-_-.----._.__---_. <br /> ID-itosal' <br /> No: of compartments----------- - ------Size-•--------------------=-------•-Liquid depth------------- ------------Capacity----------------------- <br /> Field: Distance from nearest well------------------_Distance from foundation--------------------Distance to nearest lot line----------------- <br /> Number of lines-----------------------------------Length of each line------------------------------Width of french-- -._._.---------------.---.----- <br /> Type of filter material-------------------------Depth of filter material---------------------.Total length--------------------.___________-_____.__ <br /> Seepage Pit_, Distance to nearest well__r�,vy�-_ __Distanceom°foundation_X.�.r___=i.bistance to nearest lot line:__ _---- 4 <br /> Num _ <br /> ber of'pits Lining materil_ _ 2_ <br /> a _.Size: Diameter__ 3-------------Depth___' Qo________________._ !� <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------------.------ Lining material------------------------------------- (f <br /> ❑ Size: Diameter--------- Depth----------=-----•-- ------------------------Liquid Capacity----------------------------gals. ' <br /> Privy:r Distance from nearest well----------------------r_--___-_-_-________._r-_Distance from nearest building--------------.__________________._____.._. <br /> ❑ -" --Distance to nearest lot'line---------------------_------------------------ .. <br /> . t R <br /> Remodeling and/or repairing (describe).:-----�';'4_------ ------------------ --------------------`------•--�-•------•-•----..........�------............---------------------------------------- <br /> ----------------------­------•------------•----------•----}-------- ---...-----------------------•------ <br /> ---------•- --------------••--------•----•---------------- ­­--•--------------------'-----------------------------•---------------------------------------------- <br /> k r <br /> ----------------------- -- <br /> I hereby certify-tliat I have prepared this application-and'iha+-tke work will be done in accordance with San Joaquin County <br /> `ordinances, to laws,`and ales and regulations of,the San JoaquiriiLocal Health Dis+riot. E <br /> ` T . r <br /> 1 <br /> {Signed]..r �° 'C�t/ --- ------------- -------------------------{8w^er`_aR4 ontractor] <br /> ;I( <br /> .: o <br /> f ? --------------------------------=--------(Title)---- <br /> By: k ------------------- <br /> (Plot plan, s wing size of at, loco+ion of,system in relation to wells, buildings, etc., can be placed on reverse side). t <br /> FOR DEPARTMENT USE ONLY <br /> s <br /> APPLICATION ACCEPTED BY------------- ------------------------------------ DATE ----- ------------- <br /> ---- -- - ------------------ <br /> `Z <br /> REVIEWEDBY------------- ----------`----------.-- ---------------- ------- - -- -------------------------- DATE------------- - <br /> BUILDING PERMIT ISSUED__.:. ----- <br /> - ------ DATE--------------- <br /> Alterations and/or recommendations:--------------------- ---------------------------- -- t! -----------------------.^ <br /> -------------------------------------------------------------------------------------------------------------------------------------- ----- -- -- ---------------- <br /> •----•----------------------------------------------------- ----- ------------------------------------------------------------------------------------------------------------------------------- ----------------- <br /> ---------------------------•-•---------------------------- ---- -------------•---------------- ----------------•--------------- - <br /> ------------------ - - ---- -------------------------------------------------------- <br /> r <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 W2100 <br />