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APPLICATION FOR SANITATION PERMIT Permit No. __�r�i <br /> S (Complete in . <br /> 7 <br /> I� _ Date Issued <br /> App[i ation is hereby made to the SaniJoaquin Local Health District for a permit to construct and insfall the work herein described. <br />• This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION------------ M------%; -----------•----------•--------------------------- <br /> C: Owner's Name---------- ------------------•--- --- ----•------- , ;-------- -<-7-------------- Phone.-------------------------------- <br /> Address------------------------------------------------------------------------,, ----------------------- -­------------------------------------------•--•------------------•---------------- <br /> le *Contractor's Name-------------------------------- ----- Phone <br /> Installation will serve: Residence 2 �_Apartment House F] Commercial E] Trailer Court ElMotel ❑ Othper ❑ <br /> Number of living units: __1__._ Number of bedrooms f---.. Number of baths -/--- Lot size ---- Q- --� •------ <br /> Water Supply: Public system `f Community system Private ❑ Deptli to Water Table .------- ft. <br /> Character of soil to a depth of 3 feet:- Sand ElGra el ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�r pan ❑ <br /> Previous Application Made: Yes ❑ No. rg New Construction: Yes X No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Se tic-Tank: Distance from nearest well-_____.______ Distant oundation_________ ---------Material <br /> pS+jA j No. of compartments_.._ ..___..._-_- - q Distance to nearest lot line______-- , <br /> ¢e- - -------------- Liquid de th--------------- <br /> Capacity { <br /> "'Disposal Field: Distance from nearest wel��?,�D�stance from foundation_- ____ � <br /> r <br /> Number o� lines------------- ---Length of each line-414p- <br /> --- <br /> --- ----Width of trench-_----- <br /> Type of filter material-_ .z�--- - -Depth of filter material______ -- . << _Total length_-_ <br /> �� <br /> FSeepage Pit: Distance to nearest well---------------------- from foundation--------.-----------Distance to nearest lot line_______.__.___... <br /> ❑ Number of pits----------------------Lining material--_--------------------Size: Diameter------------------------Depth-------:--- ------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------.--______________________ <br /> ❑ Size: Diameter------------------------------------ Depth------ ---------------------------------------------Liquid Capacity- .-----------------------gals. <br /> Privy: Distance from nearest well------------ -,,------------------------------Distance from nearest building--_-------------------------------------- . <br /> ❑ - <br /> Distance to nearest lot line--------`---------- --------------------------------------------------- --------------I------------------ ----- -- -----------------` <br /> i Remodeling and/or repairing (describe)--------------------------------- --------- ' <br /> a <br /> -------•------------------------------=----------•--------------------__._.••---------•--------------------------------------------------------------- - <br /> ---------------- -- ---------•-----------•-------------••------------------------------------------------------------------------- <br /> ---------- ---------------------------•-------------- •-------j-•------ ----------------------------------------------•------------------------------ <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 Locaf Health'Disfrict. <br /> --------------------------------- -----------------------•- -------- ------------------------------- -----(Owner and/or Contractor) <br /> By:-------------------------- ---•- -- -- ---------•-------------------------------------------------------------------------- (Title) = <br /> (Plot plan, showing size of lot, location of system in relation to well's, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT`USE ONLY, v <br /> APPLICATIONACCEPTED BY---- -------- ------------------- -- -------------------------�-----"------ DATE --- ----r �3--------- <br /> REVIEWEDBY---------------•---- ------ -------------------------I------------ DATE--------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------- =---------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations------------------- ---- ----------------------------------•-----------------•--••-------------------------- --------------- <br /> --------------------------------------------------------------------- <br /> ------------- -----•-------•-•-------....--------------- <br /> tl;4 - ! <br /> -------------------•-------•------•-•--------------------------------------- <br /> ---------------------- ------------------------------------------ -----------•---------------•--- <br /> ------------------------------------------ 1 <br /> FINAL INSPECTIGIV BY:__-_�-- -------------------------- ------ <br /> Date ---------------------------- <br /> * �- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Sfteet 132 Sycamore Street 814 North "C" Streef <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> f <br /> ES-9-2M 0-52 Revised W-2100 y <br />