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Tr / <br /> APPLICATION FOR SANITATION PERMIT Permit NoCad__b____ <br /> (Complete in Duplicate) <br /> Date Issued * <br /> Application is hereby made fo 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. 54 . <br /> ' <br /> JOB ADDRESS AND L CA ----- " - <br /> �Tv -------------------------------------- / <br />� Owner's Name-------- --- - -- ---- ----- - - -- ---------------- -------.-------------------------------------------- -- <br /> Phone__- ' P _._ <br />+ Address- l Q --r-,---------------------------------------------------------------------------------=-------------------- ----------- <br /> Contractor's Name------------------ ----- -------------------------------------------------------------------- --- Phone ,/ <br /> Installation will serve: Residence" Apartment House E] Commercial E] Trailer Court ❑ Motel F] Other E]Number of living units: _/___ Number of bedrooms ___/__ Number of baths --/---.Lot size ____;� 4?-------------------- <br /> Water Supply: Public system Community system '❑ Private ❑ Depth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay❑ Adobe Hardpan ❑ ` <br /> I Previous Application Made: Yes ❑ No 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 /> Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material-------------------------------------------------- <br /> No. <br /> ._____________-_____ ._________________________- <br /> No. of compartments--------------------------Size--------------------------------Liuid depth---------------------- Capacity <br /> Tf <br /> Disposal Fie, <br /> Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line____-__-_______:- <br /> Number of lines-----------------------------------Length of each line-----------------------------.Width of french----------------------------------- <br /> Type of filter material--.-----------------------Depth of filter material-----------------------Total length------------------------------------------ <br /> / <br /> Seepage Pit: Distance to nearest well____'--______Distance from foundation_____9! <br /> ------Distance to nearest lot line___________ <br /> XNumber of pits----- I-----------Lining material-------/--------------Size: Diameter__y:��_•r_____Depth___, --------------------- <br /> Cesspool: <br /> ------------------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material------------------------------.______- <br /> ❑ Size: Diameter---------------------- ---------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Priv Distance from nearest well ___---------------------------------------------Distance from nearest building <br /> ❑ Distance to nearest lot line-------- -------- `-------------------- -- - -_­ - ---------- �. <br /> F A <br /> Remodeling and/or re a' in (describe):-�A °- -- ----- -- = �� <br /> l -----------------------I--------- -•------------------- ---- --- - -- ��------------- ------------ ------ ----------- ------------;_- a <br /> --------------------------------------- <br /> ----- ------ -------------------------,--- --------------------------------------------------------------- ----------------------- ----- '----------------------------------------------------------------- <br /> I hereby certify that I ha e p ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws/a d rule acid egulations e--S-a0 Joaq Local Health District. <br /> (Signed) ----- ------- - - --------- --- ------------ ------------------=r------------ ---------------------(Owner and/or Contractor <br /> • By:_--_----------- ---- - �"�" --- --. ----- --- -- � ---------------------------------(Title).-mac '~ ------ -'----- <br /> (Plot plan, showing siz o lotjocaflon f system in rdletion to wells, buildings, etc., can be placed on reverse si e). <br /> ) <br /> ► FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- --------------------------------------------------- ---------------------------------------- DATE <br /> REVIEWEDBY DATE----- -- ---------------------------------------------- <br /> BUILDING PERMIT ISSUED-------- ----------- ------ ------------------------- DATE <br /> Alterations and/or recommendations:----------------------------------------------- - ---------------------------------------------•-----•--•---------•-------------- ---------_.._- <br /> ---------------------------------------------------------------------- --------------------------------------------------------------------------------------------------- ---------------------------------------- <br /> .___________________________________________..__..-__-__________________.________________________-_-_._______-_-____________-_-_-__--___-________________ <br /> ______________________________________________________________________________________________________________________ -r �. <br /> FINAL INSPECTION BY:--------Ir �---_ ___---- - ; <br /> Date-. ------ <br /> ---- ------------------------- <br /> I 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 /> E$-9-2M 8-51 Revised W-2100 t <br />