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1 <br /> k APPLICATION FOR SANITATION PERMIT ._ Permit No.,�..�. ...._��..._ <br /> (Complete in Duplicate) , <br /> /► �� (� gate issued'._ ------ <br /> Application is hereby made to the San Joaquin Local Health istrict for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordina No. 549. <br /> JOB ADDRESS AND LOCATION.....---. ---- -' - -- <br /> Owner's. Name-------- ---- - ------------ -=-- --- -- -- ------------------------ <br /> Address <br /> ---------------------- ---=---------------------------------------- Phone .-- ----�-� <br /> Address - --------------- - ----- -------• ------ ---------------------------------------------'------------------------------------ <br /> Contractor s Name................��... . ... -:. ... ...- -��/ <br /> i------- - - ---�-•---------•-•-- -------------- ----------------------- Phone----------- <br /> Installation will serve: Residences Apartmen ouse ❑ Commercial ❑ 'Trailer Court ❑ Motel ❑ Other ❑ '�►�X Z z k <br /> Number of living units: __ /____ Number of bedrooms o2__ 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 ❑ Adobex-Hardpan ❑ <br /> Previous Application Made: Yes ❑ Nojk� 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 /> ,.S(9,ptic Tank: Distance from nearest well.................Distance from foundation....................Material---------------.__.............................. W <br /> No. of compartments---- -------- ------------Size-------------------------------Liquid depth--------------------------Capacity--_-------•---------- <br /> Disposal Fi Id Distance from nearest well.----------------Distance from foundation--------------------Distance to nearest lot line................. <br /> Number of lines-----------------------------------Length of each line-----------------.--.--------.Width of trench----------------------------------- V► <br /> Type of filter material_________________________Depth of filter material-----------------------Total length......_____....'.... <br /> Seepage Pit: Distance to nearest we11�2 Z^'___-_-_Distance., om fo tion_ L?_._-------Distance to nearest lot line_.,, ----- <br /> Number of pits---/-------- Lining mat rial. `. _,.. ' e: Diameter-A/1 -j-11 --_-Depth. -,l lr'___________________ <br /> Di <br /> Cesspool: Distance from nearest well..'............. nce fro undation--------------------Lining material------------------------------------- b <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity--------_-- • ------.gals. <br /> Privy: Distance from nearest well---:- -------------------------------------------Distance from nearest building----------------------.____..__-___- N <br /> ❑ Distance to nearest lot line---------------------------------------------------- --------------------•--------•----------------•----------- <br /> Remodeling and/or repairing (d crihe):_.GG,ee,, ----- •. . ..... . <br /> -------- -- <br /> F. r t' F -------------------------------------------------------- <br /> I hereby certify that ( have prepared this application and that the A will be done in accordance with San Joaquin County <br /> ordinances, State s, and rules d regulation f the San Joaquin Local Health District. <br /> (Signed).........-- /"�-/----- ------------------------- -------------------------------------- Owner n Contractor) <br /> By:..................... --- -- {�:---- - -------------------------------------------------------------------- -----(Title��reversf <br /> ._rt-- - --'(Plot plan, showing size ot, locati n of system in relation to wells, buildings, etc., can be pl side <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------------------------------------- •----------------------------- DATE-------- ----------- <br /> , <br /> REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------- ••---- <br /> BUILDINGPERMIT ISSUED.......................................................---•--•-------------------=------------------- DATE----- ---------•-------------- <br /> Alterations and/or recommendations:............................ ----------------------•------------------------------- ................................................... <br /> ---------------------------•---•------------------------------------ --------.-------•- ---------------------------------------------•------...------------------------------------•-------------------•------••----------- <br /> ----------------------------------------------------_._._ ................ -------------------------------------------.--------------------------------------------------------••------------------------------------- <br /> ------------------------------------I-----.............------------------------------------------------------------------------------------- .............................................. -------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--•-------------------------------... <br /> IJ <br /> FINAL INSPECTION BY:-------------0.yyxt4- ...................... Date------------G ~ Z- r F <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 /> 5-9-2M I0-52 Revised W-2100 <br />