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APPLICATION FOR SANITATION PERMIT Permit No. - ....... <br /> (Complete in Duplicate) ��jj <br /> Date IssuecfC 0 <br /> elli <br /> Application is hereby made to the San Joaquin Local Health District for a permit to nstruct and install the work herein described. <br /> This application is made in compliance with County Ordinance o. 549. <br /> JOB ADDRESS AND ATION..__ ._..,, �___ <br /> Owner's Name------------- A =_ ---- - --- � __-_ Phone---- ---1-3' <br /> Address.... -- . -- ............. ------------ .................. ------ -----•------------------•-•------------------------------ <br /> Contractor s Name------------------------- t----- --- ....................................................... Phone_;.�..:I <br /> Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ Motel ( ther ❑ <br /> Number of living units: - ----- umber of bedrooms _/--- Number of baths _/.. Lot size ____ '__ ______________ <br /> Water Supply: Public system ❑ Community system ❑ Private,�Depth to Water TableC3ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sanlldy Loam ❑ Clay Loam ❑ Clay ❑ Ado Hardpan ❑ <br /> Previous Application Made: Yes ] No New Construction: Yes No ❑ <br /> TYPE OF INSTALLATION AND SPEC CATIONS: `` �� <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> / 1? / <br /> Septic Tank: Distance from nearest well._��_____D�stanc from) foundation _.-..__.._..M peri L_ __________ _______ _ _ __________ <br /> No. of com artments__ ae Size --Li uid de th e <br /> P 4 q P. � Capacity C1 <br /> r t rc <br /> Dispos I Field: Distance from nearest well_..__ _ <br /> Distance from foundation.-/ Distance to nearest lot line---- <br /> _ j <br /> Number of lines....... _____Length of each line________•_-.�,yr_.__._.Width of trench_____ej� ------------ ---------� <br /> Type OT filter material p 7 <br /> ' ______De Depth of filter material____ _ ��_____.Total length_________ __,,��____________________O <br /> Seepage Pit: Distance to nearest well__--------------------Distance from foundation....................Distance to nearest lot line----------------- <br /> 1_1 Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-----------------.---:--_-------- f- <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 repairing (describe: ------- -------------------------•-----•--•--•-----------------•-•--------- -----•-----------•-------------•-•-------•-------------- <br /> 00; <br /> ------------•--••-•---•-•--------•--•---------------------------•-------•----------------•--------•--------------------------------------•--------------------------------------------------•---------------------•---------- <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, Stat s, and and regulat' of the San Joaquin Local Health District. <br /> (Signed)_..___.__ ...... ------ -­ -• _. !� (Own an or Contractor) <br /> By... :----------------------------------------------------------------------------- (Titl ---- --------- ----'---------- <br /> (Plot plan, showing si Plot, location of system in relation to wells, buildings, etc., can be ed on reverse sid <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------------------------------------------------------------------------- DATE <br /> REVIEWEDBY-------------------------------- - ------------------------------------------------------------------------------ DAT <br /> ------•--------------------------------------- <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-- --- <br /> ------- <br /> Alterationsand/or recommendations--------------------------------------------------.......... -------------------•-------•-------•----------••--- --•-------------------•---•••-----•- <br /> -----------------------------------------------------------------------------------------------------------------------------------------............................-••-............................................----•- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=---•----------•------ <br /> -------------------------------------------------------•--------------- --------- --- ---------------- .............-------------------------------------------------------------------------------------------------- <br /> ------------------------------------ -•--------•------------------- ------- -- ---- ---------------------------------•----------------------------------------- -------------- ------------------------------------ <br /> FINAL INSPECTION BY:...---- ------------------= ----- Date------------ --[/--- --------_ ---- --7-3--•-----------•----------- <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 0-52 Revised W-2100 <br />