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APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> q (Complete in Duplicate) <br /> «�Dat6. 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. <br /> JOB ADDRESS AND LOCATION--- <br /> --�� <br /> Owner's Name----------------------------------------- --------------------- -------------------------------------- <br /> Address <br /> ----------------------------------- <br /> ---------- ------------------------------------------------------ ------- <br /> Contractor's Name--------------------------------- 1�t� '1 1 �f?------------------------------------------------ ---------------- Phone. <br /> i <br /> Installation will serve: Resiclencex Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: I-' Number of bedrooms __Number of baths --y Lot size -- _ r-- -r ----------------- <br /> P --Water Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table _Al—zaft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑! Clay ❑ Adobe } Hardpan ❑ <br /> Previous Application Made: Yes ❑ No X 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.)' x <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation----------------- Material---------- ---------------------------------------Capacity <br /> ,141�1f A�Cr iso. of compartments--------------------------Size--- --------------------------Liquid depth---------------- -------', <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line-__--_------ <br /> f [ Number of lines-----------------------------------Length of each line----------------- ------------Width of trench---------------------- - ---- <br /> Type of filter material-------------------------Depth of filter material----------------,f ,Total length.._._________-----------------------•----- <br /> Seepage Pit: Distance to nearest well_-0--- -----_Distance_from foundation----�----...--_-.Distance to nearest lot line--.-15-------_ <br /> Number of pits._....Z-------------Lining materialbC& __-Size: Diameter-_4z--�__.----Depth..- -57�----------------= <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--.-- .--_-----___-.----.--_--------. <br /> ❑ Size: Diameter--------------------- ----------------Depth------------------------------------------.--.---- --Liquid Capacity------------------ ---------gals. <br /> w <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------.------------------------- : <br /> ❑ Distance to nearest lot line--------------------------- -------------------------------------------------------------------------- ------------- -------- <br /> Remodeling and/or repairing (describe):-------------•---- ---------------•-----------------------------------•------••-•-------=-------- ------------------------------ <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, laws, a rules�nddregulafions of the San Joaquin Local Health District. <br /> S, <br /> 1 <br /> (Signed)_-- l ------_----( Contractor) <br /> -------- - ----------------------- ---- <br /> Itle <br /> By:------------------------------------------------------------------- - <br /> (Plot plan, showing size of lot, location of system in r tion to we11s, build] gs, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY----------- ------ -- •----------------- ------- --- ----- ------------------------- DATE------------------------------------------------------------ <br /> REVIEWEDBY----------------------------------------- - - ---- ---- ------------ -•-------------------- DATE-- ---` --f <br /> BUILDINGPERMIT ISSUED----------------- --------- - ------ -------- ---- ------------------------ DATE---- ---------------------------------------------------- <br /> Alterations and/or recommendations--------------------- ----- ------------------------------------------ ----------------------------•------..•------------------------------ <br /> ------------------•- ---------- -------------•---- --- --------- <br /> v-- orq,L, � Date----- <br /> FINAL INSPECTION BY- ------------------------------- <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 />