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�..� APPLICATION FOR SANITATION PERMIT Permit No,�.................... �- <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 /> r This application is made in compliance with C unty Ordinance No. 549. ' <br /> n t <br /> JOB ADDRESS AND C ION...__,� .0 1------_ --------- ------------------- --- --•-- <br /> Owner's Na -- - -- .............. Phone' ..��r <br /> Address. t..----- _ T` <br /> --- <br /> Contractor's <br /> -Contractor's Name --------•.. . --- - -- •------------------------------- Phone <br /> Installation will serve: Residence Apartment House ❑- Commercial ❑ Trailer Court ❑ Motel Other❑ <br /> Number of living units: _/-___ Number of bedrooms'C_. Number of baths ._/.. Lot size ..•.;�,��,a�,/��---------------- <br /> Water <br /> ______ _____Water Supply: Public system ❑ Community system ❑ Private Ve Depth to_W,,ater Keble66rft. <br /> Character of soil to a depth of 3 feet: Sand❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan <br /> Previous Application Made: Yes ❑ NooNew Construction: Yes�No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: \\ <br /> a; <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank- Distance from nearest well. n................Distance from foundation ....•.__.........Material_.. __.__.-. <br /> ` No. of compartments---------- ------------Size -----_--------------------Liquid depth--------- -- -----Capacity-- -------------- - <br /> isposal Id: Distance from nearest well-----------------Distance from foundation....................Distance to nearest lat line <br /> Number of lines-----------------------------------Length of each line------------------------------Width of trench:- . .___............................. <br /> Type of filter material.._..- _____________Depth of filter material______..:..___._____-__Total length...................._------------------- <br /> Seepage it: Distance to nearest Distance ,{y-�om,fo dation.,A0. _„Dist rice to nearest lot line ... a` <br /> Number of its_ ___ Linin materiaJ,�R� � -$ize: Diameter___.. { <br /> P /- ------- g Depth ----/.� ................ <br /> Cesspool: Distance from nearest well ..........Distance from foundation ........ ....-.Lining material...._...................-_.___--_--- <br /> ❑ Size Diameter __-_ __ Depth ___ __ _ __ ____ ___ Liquid Capacity_ __gals ' <br /> .... z - - <br /> Privy: Distance pro"m nearest weff...-- ---.. .-......X- Worn nr�arest building ............................. <br /> ❑ Distance to nearest lot line- ---- --- r <br /> _ . <br /> Remodeling and/o rspairy (describe):_- ._.-_ _ •____._ - <br /> .............. ..............................................................-----------------I... •----------------•---------•--------•-•--------•--------- ---------------•---•-•----•- <br /> ............. ----------------------------------------------- ------------------. ------•--- .. •-•--........................ <br /> . ----- --•--•----------------------------------- <br /> -------• -------• -- ----- -------------------- <br /> - --•---.------ <br /> I h reby certify that I have prepared this application and that the work will be done in accordance with San Joaquta Count <br /> ordinances, Stat laws, an ul and regulations of the San Joaquin Local Health District. <br /> (Signed)------ --- - -- --------------------------------------------------. Ow or Contracto" <br /> By:..................... ..................... -----------------------------------------(Tit ------------­---- <br /> (Plot plan, showing size o ot, location system in relation to wells, buildings, etc., can b ced on erse e. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATkQN-AC �EPTFD,BY.-• ...... .. ...... . .•_--- ---------------------. - DATE <br /> REVIEWED-BY - ------ - ----------- DATA:.- ....' �.._ ._..... :. ..�:.._.. <br /> BUILDING PERMIT ISSUED------ •-----•. -•----• --•-•-•-- --•-•--- ....----• •--•---••------------- DATE--------..._•---- = __ - <br /> Alterations and/or recommendations:-- ....................... <br /> ----------------------­- ------ <br /> FINAL INSPECTION`BY:........ ...... ................................................. Date- - ----- -- •-- ----- - ........ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 WestOakStreet 132 Sycamore Street 814 North "C"Straetr <br /> Stockton, California Ladi, California Manteca, Cali rnia y, California <br /> j <br /> ES-9-2M,10.52 Revised W-2100 " l 1/ ° V , "°. ' <br />