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APPLICATION FOR SANITATION PERMIT <br /> f (Complete in Duplicate) <br /> Date Issued <br /> Ap licati n 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 Ordi ante No. 549. <br /> JOB ADDRESS A DZOCATON- -�--- ---t ---- ( � <br /> ^� <br /> Owner's Name - -------------------_--------------------- - -- --------------------------------------. Phone_------ ---- -�------ <br /> Address 7. YF��t <br /> — ------------ `--••---------------------------.......-------------- <br /> Contractor's Name------ -- ----------------------- --------------------------------------- -------------------------------------------- Phone.--------------------------•----- <br /> Installation will serve; nces [Apartment House ❑ Commercial ❑ Trailer Court ❑ Mgfel ❑ Ot�er ❑ s <br /> Number of living units: .-1_--- Number of bedrooms ___Z_ Number of baths __ _. Lot size _9 _ ___�_ - - _ _E <br /> Water Supply: Public system ❑ Community system ❑ Private ZDepth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: <br /> Sand E] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe H rdpan ❑ <br /> Previous Application Made: Yes ❑ No g/ New Construction: Yes M No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public Agwer is available within 200 feet.) <br /> Septic Tank: Distance from nearest wel! --1_______Distarip fro fou datio ______ Mat iai________________ <br /> rip In �- --•-- <br /> No. of compartments_____.___ t_____�....__Size,�__._� _____,___Liquid dep. h_____--_ _______________Capacity.---`-�e_fOO <br /> -� <br /> Dispos I Field: Distance from nearest well_ A--___-_Distance from foundation_W_ i., <br /> _- istance to nearest lot line_ � 4NO <br /> y� ----- <br /> Number of lines______________ Length of each line_________..___ _ Width of trench.__ - --.------ -- <br /> --- ------ ----- <br /> Type of filter mate ritS ___ ___ .Depth of filter material-_________ .________Total length__________! _ .___________ <br /> Seepage Pit: Distance to nearest well---_------------------Distance from foundation------------------- Distance to nearest lot line________________. I <br /> ❑ Number of pits----------------------Lining material---------------_-------Size: Diameter---------_-------------Depth-------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation___________________ Lining material_____-_____________-___._.____--i <br /> ❑ Size: Diameter-------=------------------ ----------Depth----------------------------------------------------Liquid�Cap acity----•-------_--------------g <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------_-_----------------------- <br /> -----❑ Distance to nearest lot line---------------------Rem ling and or ;epairin (describe)_____ __ __ ------------------------•-----------•----------------•---------------g e. .... - <br /> -•--------- ---------- -----------------------•--------------- ---------------•---------•-----------------••--------------------------------------•------••---------------------------------------- <br /> I hereby certify that I have prepared this a plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, State aws_ nd rules d regulatio of,'the San Joaquin Local Health District. <br /> (Signe �. ---------1 ----------- �7�------�•_--------------------------------------------------(Owner and/or Contractor) <br /> By <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 /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY._. DATE-- rP _ __ _____._____-_______________----- <br /> REVIEWEDBY ----------------------------------•---------------------------------------- DATE <br /> " � <br /> BUILDING PERMIT ISSUED------------- ----------------------------------------------------------------------------------- DATE-------- <br /> .. <br /> Alterations and/or recommendations:-------------- -----------------------------------------------------------------------------------•- <br /> -­-------------- <br /> -------------------------------------------------------------------------------------------- ------------------------------------------------------------------------ ----------------------------------------------•------ <br /> -------------------------------------------.------------------------------------------------------------------------------------------------ -------------------------------------------------------- -•------------- <br /> �_IE3FINAL INSPECTION BY:----- ------------ Date-- --------� - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Sfock+on, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 <br />