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' ./ APPLICATION FOR SANITATION PERMIT Permit No_ _____ --------_ <br /> (Complete in Duplicate) 223 <br /> 1 Date lssudv.-. f <br /> Application is hereby'made to the San Joaquin Local Health District fora permit to cpnstruct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. x' <br /> JOB ADDRESS ANMCATI0 ' `,a _.._s. , y ~--= -- . =. -'.`--- <br /> Owner's Name.... -- --- ------ ----- --- - ---- e- -•--- <br /> Address e- <br /> -------------------- <br /> ------------------------------ <br /> -- -- -•------------•--- <br /> Contractor's Name____________ ____ _ , _�__ ,�_ ___ Phone--- <br /> t�_., <br /> Installation will serve: Residence Apartment House E] Commercial E] Trailer Court ❑ Motel ❑ Other E]Number of living units: ___/_/___\Number of bedrooms Z. Number of baths .../. Lot size ______ _________________ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table',—1? ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ElPrevious Application Made: Yes ❑ NoX New Construction: Yes rb"No El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tanj: Distance from nearest well______________;_Distance from foundation....................Material-____ -_:_____ -_.______ ------- <br /> No. of compartments------------- ----------Size------------_-- ------------Liquid depth----- ------- ------- Capacity----------------------- <br /> Disposal <br /> - •-•--•---------- <br /> Disposal ie Distance from nearest well __________:_Distance from foundation....................Distance to nearest lot line................. <br /> r Number of lines-----------------------------------Length of each line----------------------------_Width of trench-_--------------_--_---------- <br /> Type <br /> ---- •--Type or filter material-------------------------Depthofiaterial_•--------------- Tota) length.-----._...------...- <br /> See a ePit; Distance to nearest well-___-��r -___.-_Di tion____,�_G'__�___.Distance to nearest loteNumber of its____ __________ Linin ateraze: Diameter_. . ` De th__-�6�__.._._..___._..._ <br /> p --- g pCesspool:, Distance from,nearest well-__________•_-___ •stantion. -_-_-___- _____.Lining material____ ____________________________ <br /> ❑ Size: Diameter----------- - ------------_Dept --•-•---------------------------- ---------------Liquid Capacity----------_---------------gals. 4/1 <br /> Privy: Distance from nearest well-------------------------- ------- <br /> ___________Distance from nearest building------------------------------------------- <br /> Distance <br /> __.__.Distance to nearest lot line <br /> . describe :___--line---------� ----�----------- •- -- ----- ----- -•-�---- ------Remod i airing- --•-----•--------•-----•--------•-- .........................................------•------------------- <br /> ---•-•-- <br /> l - r <br /> , <br /> --- --------•--•--- ----------- •-• ----•--••- <br /> r <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, State,laws, and rules and regulations of the San Joaquin Local Health District. <br /> f <br /> (Signed) ` � 7 :� �- Owner /or Contractor) <br /> By: --------� ( ). . r' ,� r 1;� ----- <br /> Y' � -�- -----------------•-----------------.._-----------------------•._-----------------Title_._ - �---- ---- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse sid!4- <br /> FOR DEPARTMENT USE ONLY y <br /> APPLICATION ACCEPTED BY----------- -- ------'------------------------------------------------------- DATE............... <br /> r <br /> REVIEWEDBY---------------------------------------------- ------------------------------ --------------•._------------------_------- DATE.......................................... <br /> BUILDING PERMIT ISSUED................................................................................-----•--•----••-•-•-• DATE......................--------- <br /> Alterationsand/or recommendations:--------------------- .......................................---------------------................................................-------------------------- <br /> -------•-----------••----------•-------------------•--•---•----•._.•----•--•-------------••----------....----------------------•----•---•----•-------------------•--.._---------•-----•-----•----•-•------•-------••----•----- <br /> ---------•---------------------•----------------------------------------------------- ,-, ------------------- ----------••--••---------------------------------------------------------------------------------- <br /> -•------------------------ --------------------------- <br /> --- ---- ---- ---- ---- <br /> ----------------- ----------------------- ------ ------ --- � - --- ...................... -- - -•- <br /> FINAL INSPECTION BY: --•-----•--------. a 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 /> ES-9-2M 10-52 Revised W.2100 <br />