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APPLICATION FOR SANITATION PERMIT Permit No. .__(�_- � . <br /> (� <br /> (Complete in Duplicate) <br /> Date Issued __-. <br /> Applica+ion 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. <br /> �i. � / ------------- ----------------=------------------------------------ <br /> JOB ADDRESS AND O ATION -------- ___-.-___-1r-�� <br /> via <br /> Owner's Namee--------- Phone <br /> Address-------Pf-a._7------- ` -------------- -------•---------- ---------- �� <br /> /� �] _ --- <br /> Contractor's Name------------------------- �----s '�' 1•------------------------------------------- ------------ Phone o-4a__--- <br /> Installation will serve: Residence [-'-Apartment House ❑ -Commercial.❑ Trailer-Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _1---Number of bedrooms -.Number of baths -I--- Lot size ----S4 ----------------------- <br /> Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table ,/ t. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel 0 Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [9"Hardpan ❑ <br /> Previous Application Made: Yes ❑ No T----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 /> eptic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material----_---_____----------------------- ----------. <br /> % No. of compartments-------------------- ---Size-------------------------=---_Liquid depth--------------------------Capacity----------------------- <br /> �sp sal Field: Distance from nearest well............'�-Distance from foundation------_-_--------- Distance to nearest lot line----------------- <br /> Number of lines---------------------.------------Length of each line-------.-------------------.-.Width of trench-.-.------------------------------- <br /> Type of filter material----r-y-,-.._' .,-..,Depth of filter material--'..___-..----------,Total length----------------------------------- <br /> See a e P' Distance to nearest well_�iSJ.-1'' <br /> p g rN -Distance from f undation----�Q._-------.Distance to nearest lot line__/4___.---_ ' <br /> Number of pits------ - ------------.-Lining material..----- - - - Depth----o2'°--------------------- \ <br /> � -'--.Size: Diameter_---_3 3.-_ <br /> Cesspool- Distance from nearest well-----------------Distance from foundation--_ -----------------Lining material___--______-.-------.---_.---_----.. (� <br /> ❑ Size: Diameter------------------ ------------ ------Depth---------------------- ------Liquid Capacity----------------------------gals. E <br /> Privy: Distance from nearest well------------------------------------------------Distance from nearest building_-___---.-------.---.--.-__----.-----.-. <br /> ❑ Distance to nearest lot line--------------------------------------------------•---------:-• -------------------------•-------------------------------------------- <br /> . i <br /> Remodelingand/or repairing (describe)-------------------- -------=---------------------•----------------•--•-•---------------••-------••-•-----•----:---.....----------------•------------ <br /> -----------------------------•--•-------------•-----------------------------------------•----=-----•----------------------------------------------------------------•----1­---------- <br /> -------------- --------------------- -----------------­--------•----------•------------------------------------------------------------------------------------------------------------------------------•------- <br /> I hereby certif that I have prepared this application and that the^work will be done in accordance with San Joaquin County <br /> ordinances, State w , nd rules and regulations of the San Joaquin Local Health District. <br />( [Signed) <br /> '� _-..�'Y��•_---------�--- Owner and/or..Contractor) <br /> BY= ----------------------------- <br /> '.. - l ---- ---- ------------------(Title) Vj <br /> ------------- <br /> (Piot plan. showing size of lot, location of system in relati to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT U-SE ONLY <br /> APPLICATION ACCEPTED BY------------- --------------- DATE <br /> REVIEWED BY.- = '' -- DATE <br /> BUILDING PERMIT ISSUED----------------------------------- -------------------------- •--------- DATE <br /> ------ --------- <br /> ��' ----------------------------•---- <br /> Alterations and/or recommendations:------.-------------- �� �-- <br /> •----- ------------- --------------------•---- <br /> .9- �----- ---------------------------------------- -----------------------------------•---- <br /> = - <br /> ----------- --------------------------------------------- ------=------------------------------------------------------------------ <br /> ---- -----------------------�------------------------------ ------------------------ ------ <br /> . . T <br /> FINAL INSPECTION BY:.-K � ----•-------------------- ------------ 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 Lode, California Manteca, California Tracy, California <br /> 1 ES-4-2M 145446 ATWOOP 1254 - <br /> 4` <br />