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APPLICATION FOR SANITATION PERMIT Permit No. .__- a_--. <br /> ny" O t (Complete in Duplicate) J q <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 Ordinance No. 549. L <br /> JOB ADDRESS AND LOCATION.. _ <br /> ---------------------------- <br /> jp <br /> Owner's Name t a � --------------------------- -------------------------------------------- Phone------------------------------------ <br /> Address......................................................-•------------•---------------------•-----------------...-•-----------•---•----•----••--•----------------------- <br /> Contractor's Name-------------------------------- ---- --------------------------------------------------------------------------- Phone................................... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel, ❑ Other <br /> Ej <br /> A <br /> Number of living units: __ er of bedrooms_ Number of baths _ Lot size ------ I/_ ---. ______________________ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ravel E] Sandy Loam ❑ .Clay Loam E] Clay [:] Adobe ardpan E] <br /> Previous Application Made: Yes F] No New Construction: Yes leo ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if p blit sewer is available 200 feet.) <br /> Septic Tank: Distance from nearest well._;1 aftfDistanc from fours at•on� __.__.Material---- ��- <br /> 1� No. of compartments__-- ----- '-----.Size----- ;-- -- GyMqu h------- Capacity------ --(�--�• Iif <br /> NJ <br /> Disposal Field: Distance from nearest !Y_S&-Distan �"r•2 gbun"dation-_ _ -___ ._._Di <br /> nce to nearest lot ling------ <br /> h <br /> Number or lines_____________ ___i. ___--_Lerigth of each line-.3p''_�_ E+_�+� i t of trench_-____-_�A_-_�_._.___.______ <br /> Type of filter materia � -------Depth of filter material-----�•-0-----------Total length_____---_ <br /> Seepage Pit: Distance to nearest well--------_-------------Distance from foundation....................Distance to nearest lot line_ -.-. <br /> ❑ Number of pits----------------------Lining material_----------------------Size: Diameter-----------------------Depth--.--------------------.-------- <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 /> Remodeling and or repairin scrl ------ - ,t�T ---------------- ----- � ------------ -- ._---------------------- <br /> pt <br /> ------- - --------------•--�-'-- ---- ---------------------------- <br /> -------------- --- -------------------• --- --------------------•---------------- ----- ---•--------------- ----- --------•------ -------- <br /> ------•-- ---- ----------------•-------------------------------------------------------------------------------------------------------•----------------------------------------------------- -------------------------- <br /> I here y certify that I have prepared this application and that the work will be done in accordance with S Joaquin County <br /> ordinances, State l and rules and regulations he San Joaquin Local Health District. <br /> (Signed)-- . .....------ ----------------------------------------------------------------(Owner and/or Contractor) <br /> (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 /> APPLICATION ACCEPTED BY------------------_------- :-------- ---------------_----------_------------ DATE---------dg�- "� � ------------------- <br /> REVIEWEDBY_------------------------ ------- --------------------------•--------------------------------------------------------------- DATE---------------------------------------------- ---- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------•--•--------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------•- <br /> -•---------------------------------------------------- - ._.... -------- ------- -------------------------- --- -- <br /> �b -----I . -------- 1.�' --------------------------------- <br /> ----------------- . .. <br /> FINAL INSPECTION BY---------- --------- -P0_ _7Z-&--------- 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 />