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APPLICATION FOR SANITATION PERMIT Permit No. .._ ._....__.... <br /> ` (Complete in Duplicate) <br /> Date IssuedAgg <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> is application is made in compliance with County Orden ce No. 549. <br /> JOB ADDRESS AND CATIO ______________ ___ 4"- <br /> ----------------- <br /> Owner's Na ----- - ------- --- Phone <br /> ---- ------------------ <br /> Address �x ----- --- <br /> ---- ------------ <br /> - <br /> Contractor's Name f ---------------------------------------------------------------- Phone--- = -- / <br /> Installation will serve: Residence's Apartment ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ O her ❑ <br /> Number of living units: __-/_(___ _Number of bedrooms 2__ Number of baths _/.... Lot size ------- �,11 ------.__-.•__.-.__ <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 /> Previous Application Made: Yes ❑ NKICATIONS:New Construction: Yes No ❑ <br /> TYPE OF INSTALLATION AND SPECT <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 /> Dispo I ield: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- <br /> Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- <br /> fiType oT' filter material_________________ ___ Depth of filter material-----------------.-----Total length------------------------­---- <br /> Seep <br /> __--_--.____•--___-•-___.-_-._.._.___. <br /> Seepage Pit: Distance to nearest well . � Distance from f ndation_. --•..--.__-.Distance to nearest lot line <br /> /� <br /> Number of pits-_.---tom"__--____ ening material_ _. .__ _.___Size: iameter___�_�.--------Depth___._-___--- <br /> _-_._--.- <br /> e;!'ool: Distance from nearest well_________________Distance from foundation--------------------Lining material----------.__-.__-_______.._-.___-__ r <br /> ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity--------------------.-----•-gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------____------------------._:_-__.-_. <br /> ❑ Distance to nearest lot line--------- ------ --- ------------------------------------ ---- --------------------------------- ---------------------- <br /> A/7, <br /> --------------------- \ <br /> Remo ling and/or repairin tribe):_ _, T �. __-- _____ ------ ... ... .. ...... <br /> __ <br /> f <br /> -- ------------•--- -- --- ----------- ---------------------------------------•--------------------•-------------------------------------------------------•-•----------------------------------------•---------------- <br /> I hereby tify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, .to law , d rules a �7gulations of the San Joaquin Local Health District. <br /> (Signed)--------:� ---j----- - --- --- --------------------------------------------------------------------------------- --- (O nd/or Contractor) <br /> By:.................... — - - (Title- - - <br /> (Plot plan, showing size of f, location of system in relation to wells, buildings, etc., can be celon r vers ide). <br /> O PA MENT U ONLY <br /> APPLICATION ACCEPTED BY------ ------------ DATE.... ' <br /> REVIEWEDBY-_--------_----------------------------- ------------------------------------------------------------------- <br /> � _ ---- -- ------------ DATE.......`--------------------------------- -- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- <br /> Alterations and/or recommendations:-.--------------------------------------------------------------------------------------------------------------------------------------------- ----------- <br /> --------------------------•--•------------------------------------------------------•---------------- ----------------------------------------------------------------------------------------------------••......--•--•--•-_.. <br /> ---------------------------------------•-•-------------------------------------- -------------------------------------------------- -------------------------------------------------------------------------•---------- <br /> --------------------------------------- ------------------------------------------------------------------•--------------- --------------------------------------------- ----------------- '---------------------------- <br /> •FINAL INSPECTION BY---------------- - ---------�r-----�---•---------------- Date...--TJ 1 -----.t°__ ._ <br /> ---------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 84 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 <br />