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s <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <br /> Applica+ion 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. A;91 <br /> JOB ADDRESS AND JOCATION-------- ----------------------- <br /> Owner's Name----.. ------- ---1-1----------------------- - ------ Phone------------------------------------ <br /> ------------------- <br /> --------------------------•-------- <br /> Address....- = -�a• -- ---------------------- ---------------------------•------------------------ ------------­--------__--- <br /> ---- <br /> - ------`-__-.-. <br /> - <br /> Pho /� `__- <br /> _ <br /> -Contractar's Name <br /> Installation will serve: Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: --#---- Number of bedrooms J.._ Number of baths ____ Lot size ___ 72f----,k-" <br /> ___ __ --- a____________-- <br /> Water Supply: Public system 6—00`mmunity 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 6�ardpan ❑ <br /> Previous Application Made: Yes # ❑ New Construction: YesYJals ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> .(No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest welLe;7Z _Distance from <br /> foundation____ ___.__. <br /> No. of compartments--------- ...Size_rA— <br /> depth--- ----------Capacity- fl-- - <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line_______________-. <br /> Number of lines-----------------------------------Length of each line----------------------.------.Width of trench.---------------------------- ----- <br /> ��� Type of filter material_.......................Depth of filter material--------.------------.Total length------------------------------------------ <br /> Seepa e_P Distance to nearest well----------------------Distance from.foundation--------------------Distance to nearest lot line----------------- <br /> Number of pits----------------------Lining material__.---i- ;-------Size: Diameter--.------- -- ---------Depth.---------------•--------------- <br /> Cesspool: Distance from nearest well----------------- 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 line------ -------------------- ----------------------------------------- ---------------- --------------------------------------- <br /> Remodeling and/or repairing (describe):-- -- -- - ------ -------- ----------------- <br /> - - --------- ----- <br /> -----.> / <br /> ---------------------------------- ------------------•--------------------------- •-----------•-------------------------------------------••--------•---------••---------------------• ------------- <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, law hands and egulations o the San Joaquin Local Health District. <br /> 2 - -:- -. ntractor <br /> (Signed) <br /> By:------- - ----- -------------------------- -----------------------------------------(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 /> APPLICATIONACCEPTED BY---- --------- ---- :--------- -------------------------------------------------- DATE--------s�---------------------------------------- -- <br /> REVIEWED BY------------------------------------ ------- -- ------ DATE was, <br /> BUILDING PERMIT ISSUED--------------------- ------------ ----------- _ DATE----- -- ----- --- <br /> Alterations and/or recommendations: -- Is - --------- --------- --------------------------- -----•-----------•...------... .... ----- <br /> ---------------------- -------------- ----- ------------- -------------- ------- <br /> FINAL INSPECTION BY:--- /L ---------------------- •----- Date-----4-_J C"Z---------------------------------- <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 /> S Es-9-2M 14S446 PT-CD 12.54 C _f <br />