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APPLICATION FOR SANITATION PERMIT Permit No.Jr. <br /> (Complete in Duplicate( <br /> Date lssuedy _ qs* <br /> Appl'rca+ion is hereby madeatp,the Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application.is mace in 85'm' pliance with County Ordinance No. 4 <br /> JOB ADDRESS AN CATION__.1 :_-f.- ... . . . . ... ...... <br /> Owner's Name - •••-- '---------- ••--- ---------------- Phone...9_._'� ' <br /> Address ---••--•------ = <br /> Contractor's Name-- �► ..................................................... Phone--. .._/ . <br /> Installation will serve: Residence Apartment House ❑ gqCommercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __/___ Number of bedrooms -_L Number of baths ----/ Lot size •._ ,�sr_®._.e `__ _-r................... <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table�Vo! 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 ❑ Nx� New Construction: Yej,.W No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS:, <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> tic Tank: Distance from nearest well.................Distance from foundation.....................Material-------------........................._.......... <br /> qi • No. of compartments____________ ___ Size................................Liquid depth--------------------------Capacity-. _ <br /> osaI Fri Distance from nearest well--------------- Distance from foundation..........____::.._.Distance to nearest lot line................. <br /> P <br /> Number of lines_____ ___________________________Length of each line..............................Width of trench................................... <br /> a <br /> Type of filter material------------------_-----Depth of filter material-----------------------Total length...._-_.. _______-•--_--•_.-_._..__..._. <br /> Seepa a Pit: Distance to nearest well,'_-.-__-Distance f m f dation,,r'_�U...........Distance th teare#lot line_.$.— <br /> Number of pits.... -----------Lining materi .Size: Diameter--�..--, -.:._DepK-------_ <br /> Cesspool: Distance from nearest well------_----------Distance from foundation.....-...............Lining material.__ ............. <br /> ❑ Size: Diameter---------------------------------------Depth------------------ ------Liquid Capacity -----------• •••--....gals. <br /> Privy: Distance from nearest well ------- -----_____.•____________-_._._Distance from nearest building......_------._.__- _-...._____--___- <br /> ❑ Distance to nearest lot line--------------- - ----------------------- --•--- <br /> ----- <br /> Remodeling S54r repairing (describe):...___ - -- ------- ------ ...... .---• __ _.. -- -- ----------- --- <br /> ----------------------------------------------------•---------------------------•-----------•-------••---•--------•------------------ •---- -------- ------------------•_---------- <br /> ------------- ------- --------------------------------- ------------------------------------------------------•-----------•- -------------------- -------•-------------------- <br /> I hereby certify that 1 have prepared this application and #hat the work will be done in accordance with San Joaquin County <br /> ordinances, Statnakf <br /> and regu of the San Joaquin Local Health District,' <br /> (Signed).. ._.....• •..;.(Owner and o Contractor) <br /> r <br /> By:..................... •----- ---. -• ....... c.................................................................(Title). �'` <br /> (Plot plan, showing size of I ocation of system in relation to wells, buildings, etc., can be pl on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- ---------..................................... DATE_ .................................... <br /> REVIEWED BY------- -------------••--•. ------------------------------------------------------ DATE-':.... <br /> BUILDING PERMIT ISSUED------------------------------------ ...................................... DATE.............>1' ------ --------- <br /> Alterations and/or recommendations:................................................................................................................................................................ <br /> ................ ----•••-- •--•--. • -- -------...................................... <br /> FINAL..INSPECTION BY...... _. ............. Date----•---- ✓ . ............ •--•-•--. _....-- •-•-•-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North 'V'.Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California „- <br /> ES-9-2M Revised W-2100 � . ,� <br />