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APPLICATION FOR SANITATION PERMIT Permit N ________________ <br /> (Complete in Duplicate) <br /> Date Issued __/i/ <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 0 d nce No. 549. <br /> JOB;ADDRESS AND,LOC ON- --- ------------------------------------------------ <br /> Owner's Name------------------- ----------------------------- Phone------------------------------------ <br /> Address--------------------------- <br /> -----------------------------------Address--------------------------- ----- --- - ------------- ---- ---- - --- -=-----------`-----------------------------------T-------------------- -� -- <br /> Contractor's Name d - =`,.," --•--------------- ------ Phone- <br /> ---------- <br /> hone <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Treiler Court ❑f Motel ❑ Other ❑ <br /> Number of living units: ___ er of bedrooms .`---_ Number of baths -/- Lot size _ ---------- <br /> Water Supply: Public system Community system'❑- Private'❑ Depth to Water Table -------- ft. } <br /> Character of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam ❑ Cl oam ❑ Clay ❑ Adobe �adpan <br /> Previous Application Made: Yes ❑ No Dr New Construction: Yes o ❑ <br /> TYPE OFfINSTALLATION AND SPECIFICATIONS: 1 <br /> (No septic.+ank or cesspool permitted if public se is available within 200 feet.) <br /> Septic Ta Distance from nearest well W._ Distance from foundation---41Y-.......Mater- --------------- -------- ----- -- <br /> G/ <br /> ❑ No. of compartments' __________ Liquid deh-_-_ _ _ _- Capacity___,_ _____. <br /> t� .- W . <br /> R .Distance to nearest lot II je___k.,� <br /> Disposal F- Distance from nearest wel ,�._ istarce from foundation__�►�_____ <br /> EPOONumber of lines___ ength of each line___ ^Q��1d---Width of french---- _ _ <br /> I/ jr <br /> Type of filter material__�r _ _Depth of filter material___/_?f________-Total length----.___ _----------__________ <br /> Seepage Pit: Distance to nearest well______________________Distance from foundation--------------------Distance to nearest lot line <br /> ❑ Number of pits------------------.- _Lining material-..-------------------.5ize: Diameter-------------------- Depth--------------------------------- <br /> ,Cesspool: Distance from nearest wel!------------------Distance from foundation--------------------Lining material--.-__------_______________-__-______. <br /> Size: Diameter-------------------------------------De th------------------_.__----------------------------------------------------Liquid Capacity gals. <br /> Privy: Distorce from nearest well _________________________________________Distance from nearest building------------------------------------------ <br /> --------- <br /> ❑ Distance to nearest lot line <br /> ---------- <br /> Remodelingand/or repairing describe :- -____ ...... <br /> ---•-----------••--•---------------------------------------- - ------------ ---------------------------- -- ------------------- ------------------....---------------------------------------- <br /> ---------1— - ...._.. <br /> " ------------------------------------ -----------------------------------------.------------------------------------------------------------••-------------------------------------•--------••------------------------- - ---- <br /> I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County <br /> ordinances, State laws an rules and regulation of the San Joa uin Local Health Distr'ct. <br /> Signed_________- _ `' __ .. � ._ , Own f and/o ontractor) <br /> (Signed) c <br /> --- -- -- - -------- - ------- <br /> ElY:.... � r---•- - ---- --------- -- <br /> --------------------------------- --------------------------------------(Title)---- ' ---- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> OR AI RTMENT US ONLY <br /> APPLICATION ACCEPTED BY---- q---- - - ----------- ------- --•---------- ----------------- DATE----------3.---�--- J-7j------------------- <br /> REVIEWEDBY--------------------------------------------- ------ DATE------ ----------------------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------ --••----------- ---------------------••---------- <br /> Alterations and/or recommendations:--------- --------------------- ------------ -------------------------- -------------------------------------------------------------------------------- <br /> -------------------------------------------------•---------------------------- -------------------------------------------------------.--------------------- ----------------------------------------------=------------------ <br /> --------------------------------------- ------•--------•---•••---------•-----------------------------...---------------.----------------------------•-----------------..----••------------------------------------------------ <br /> - ------- ---- <br /> FINALINSPECTION BY--------------=--- --- ------ --------------------------------- Date----------, 7-- ----------- -------- ------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 134 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 JO-52 Revised W-2100 <br />