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APPLICATION FOR SANITATION PERMIT " "Percrtit No.o�t_��_._�._ <br /> r ` <br /> (Complete in Duplicate) � q (� ! <br /> ! ! I Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permifi t construct and install the work herein described. <br /> This application is made in compliance with ,County Ordinance o. 549. <br /> JOB ADDRESS AND L TIO ____:_ /_ <br /> Owner's Name .. <br /> ---------------- ------------------- ------ ------ Phone,,-_-.-..---- --------- <br /> Address............. -- -- --- -• - --- --------------------------•-------- - <br /> Contractor's Name 4 =7 �• '-------- . Phone.,,?..� 5. <br /> Installation will server Residence partment House ❑ Commercial ❑ railer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _ Number of bedrooms. Number of baths_ Lot size .�C~ __ ,� _........,x--------_______ <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ft. <br /> tCharacter of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay ❑ Adobe 'Hardpan ❑ <br /> Previous Application Made:: Yes ❑ No New Construction: Yes ❑ Ng, '� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank qr Distance from nearest well-----------------Distance from foundation....................Material------------------------------------------------- <br /> No. <br /> _____________ _____ -_____,_______.___________- <br /> No. of compartments Size =Liquid depth ------Capacity----------------------- <br /> Disposal <br /> ---- ------- ------- <br /> Disposal Field.. Distance from nearest well.-----------------Distance from foundation....................Distance to nearest lot line----------------- <br /> x <br /> Number of lines_________________________ __Length of each line ______ ___-_-_-Width of trench----------------------------------- <br /> Type or filter material ___-__Depth of filter material----------------------- <br /> Total ------------------------------------------ �. <br /> See age Pit: Distance to nearest wel ___---Distance f m f dation_� '/____--_--.Distance to nearest lot line <br /> Number of pits____ /-_____ __ Lining material '_�___Size: Diameter_..._ __ Depth_____ __ T\ <br /> Cesspool: Distance from nearest well_____-__---.____Distance from foundation-----------_--------Lining material-------------------------------------- <br /> 01 Size: Diameter--------------------------------------Depth-------•-------------------------------------------Liquid Capacity..--------------------------gals. <br /> Privy: Distance from nearest well _________________________._--.-----------------Distance from nearest building------------------------------------------ <br /> ElDistance to nearest lot line------- -----`----•- -•-------•---------------------------------•--•---•-•---------------•------•---------------------------•---------------- <br /> Remodeling and/or,repairing (describe):----------- -- -•-----•--------------••----•--•-•--------------------•-- -------- --------- ----•--•-----•-------•------ <br /> ---------------•-----------------------------------------------------------------------------•-----•--------------------------------------•--------------------------------•------------------------------------------------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State law a rules d r ul ions"of th San quin al;Health District. <br /> r n <br /> (Signed)_... �j __- ____' -G__ ------ ,- � _-__(Owner and/or Contractor) <br /> By: - - .- - .... .. (Title ` L = ' -------------- <br /> (Plot plan, showing size of 10 , loca+ion of system in relation to wells, buildings, etc., can be pi ced on reverse e). <br /> - FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B ---------- ------------------------------------------------------------------------------ DATE <br /> 11�REVIEWED BY------------------------- -- ------ -------------------------------------------------------------------------------- DATE.. <br /> BUILDING PEWIT ISSUED DATE- -------------------------- --- <br /> Alterations and/or recommendations---------------------------------------------------------------------------•------------------------------------------•--------------------------------------- <br /> ---------------------------•------------ ------------- ------------------------------------------------------------------- ---------- ------------------------- -------------------------------------------------------------- <br /> ------------------------------------------------------------------- --------•- -------------------------------------------- -------------------------=----------- ------ <br /> FINALINSPECTION BY---------------------------------------------------------------- Date---------------------------------- ----------------------------------- <br /> SAN <br /> ---SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South.ltmerican 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 />