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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) — <br /> Date Issued <br /> r <br /> Application 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------------------------------------ <br /> Address ,a !p r ------------------------------------------- <br /> ----- <br /> -------- ----- ------------- <br /> ----- --- <br /> - --- --------------- <br /> �Ue- � ,p <br /> Gontractor's Name t f -- ---- �r • hone __ <br /> 3 <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Moto ❑ Other ❑ <br /> Number of living units: _ ___ N mber of bedrooms /---- Number of baths /-_ Lot size __--____ a � <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table.J ft.- <br /> Character of soil to a depth of 3 feet: Sd Tavel 1­1Sandy Loam F-1 -ay Loam El Clay E] Adobe Hardpan El <br /> Previous Application Made: Yes F] No <br /> No New Construction: Yes No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer 's available within 200 feet.) <br /> tante from foundation__ fr <br /> Septic Tar ' Distance from nearest weII�Y_�_ -I----------Mate t I_ __ __.G-!` i -=_, <br /> Ek No. of compartments__,�------------------Sr - -._Liquid depth----- <br /> _-- .Capacity____ <br /> Disposal Fi Distance from nearest�well_/I�L!'� stance from foundation_-/-_t�__ ---Distance to nearest lot in ___________ <br /> 040 Number of lines-----,r ------------�__ F <br /> gth of each line d ---Width of trench-------- ---------------- <br /> Type of filter material_____ th of filter material___ _ ` ___Total length_______ ______ <br /> ---------------- A\ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation---------_----------Distance to nearest lot line________________ <br /> ❑ Number of pits----------------------Lining materiaf-----------------------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 /> ❑ Distance to nearest lot lire--------------------------------- --------- -1---------- ----•-------- ------------------------ ----- <br /> Remodeling and/or repairing (describe):_______________ __ ___ ___ ______�_____- ______________- <br /> - ------------------------------------------------------------------------------------------------- o <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> 1 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, nd rules and regulatio s of the San Joaquin Local Health District. <br /> (Signed)-------- 4- _14--i- rt " )Owne d/or Co +factor) J <br /> ti ,Af ----------------- <br /> By: (Title} <br /> ---- _ --- �= <br /> (Plot plan, showW size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY , <br /> l <br /> A,PPLICATION ACCEPTED BY------ v-� A- --• '"_f........� 0_ ------- DATE-- P_Z?. 'T� <br /> ------------------------- <br /> REVIEWED BY------------------------------ ------------------------------------------------------- <br /> - <br /> ------------------------- ------------- DATE---------------- ---------------------------------------- <br /> - <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------- ---------------------------------- <br /> Alterations ar d/or recommendations:--•--------------------------------------------------------------------------------------------------------------------------------------------------------•--- 4 <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -------------------------------------------------------------•----------------------------------------------------------------------------•------------------------------------------------------------....-..--------------- <br /> ------------- <br /> ---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:-----------�X/1 _66 ------------- 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 /> E5-9-2M 8.51 Revised W-2100 <br />