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41 <br /> �•,, ,•.4� � � ` APPLICATION FOR SANITATION PERMIT Permit No. ........ <br /> 1 Iy (Complete 1n Duplicate) <br /> Date Issued .......__.�/__._ <br /> !A _ <br /> Applicatic� 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 /> Owner's Name ---------------- --------------------------- ------ Phone---3'--�7--3F4------ <br /> Address-----..._9'&-3----- �� --------------------------------------------- ------------------------'-••-----•----------------- -- --- <br /> Contractor's Name-------- --- Phone...�_,1�.___--- 2_� <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living its:un <br /> �___ Number of bedrooms __�__ Number of baths _„�__ Lot size ________t,�a___-`__,!�___/'____ ____ <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 ❑ .Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ NOX New Construction: Yes ❑ NOX <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: a <br /> a <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. of compartments----------- ---------------Size--•------------•---------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal <br /> ---------- ------Disposal Field: Distance from nearest welf------------------Distance from foundation--------------------Distance to nearest lot line_______--___.__-� <br /> ❑ Number of lines-----------------------------------Length of each line------------------------.------Width of trench------------------------------------ <br /> .Type <br /> ----------------------------------.Type of filter material-------------------------Depth of ------------- --------Total length--------------- •--------------------- �N <br /> .� D .S <br /> Seepage Distance to nearest well______ __ ________Di0ance <br /> rom fours at ____....___.Distance to nearest lot line__' ________. <br /> Number of pits------f'_______--Lining mat �__ iz . Diameter__ .3-4-------..Depth_..._..12-A--------------- <br /> Cesspool: . Distance from nearest well-----_`'---------Difrom fo anon_._-_.______._.___.Lining material__________________________________-Size: Diameter-----'-------------------------------Deo'P <br /> Distance <br /> Capacity gals. <br /> Privy: Distance from nearest well-----_-------------_------------__'--------------Distance from nearest building__.__._._________________.._ <br /> i ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------- - ----- --------------------------- <br /> .1 a» t <br /> Remodeling an or repairing (clescribe):____ ` <br /> 41:2 LeVUR <br /> .____r-_r___ __________________ <br /> w. x <br /> ______________--------------------------------------------------------------------------------------------------------------------------------------....-------------------1__._,-------------.------------------------------- <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 laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)------------------------------------- ------ w----. caner and/or Contractor) <br /> --- --- rnwner and/or <br /> -- {Title) <br /> ----- -------------------------- --------------------------------------------------- <br /> (Plot plan, showing size of lot ocation of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY. ;- _� -------- DATE <br /> REVl1=WED BY -------------- <br /> ---------------------------------------------- DATE-------------- ------------------- <br /> BUILDING PERMIT ISSUED-------------------------------------------------------------•--------------------------------------- DATE---------------------------------------- <br /> - ----------------- <br /> Alterations and/or recommendations:------'----------------------`--------------------------------------------------------------------- --•-----•--------------------- .----... <br /> .................................•------------------•------------------------ ----------------- -------------•-••-------••-•--••---••---------------------------------....... ------------------------------------- <br /> ---------- ----- ------- ---------------------------------------------------------------------------- <br /> r. <br /> FINAL INSPECTION BY:. 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 Lodi, California Manteca, California Tracy, California <br /> 1 ES-4-2M 10-52 Revised W-2100 <br />