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APPLICATION FOR SANITATION PERMIT Permit No.� <br /> (Complete in Duplicate) Date Issued —---A vhi3 <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 Coun y-Ors,inancp No. 549. <br /> JOB ADDRESS D LOCATION -- ----- ---- ---- -- -- -- --- - ---- --------------- ------------------------------------------ <br /> Ir <br /> Owner's Name-------- ---- - ---- --------- ---- ----- --- ------------------------------ -------------------------------------------- Phone- --------- - <br /> Address.....;Z­0---Z-- ----------- ---- ----------------------------------------------------------------------------------------------------- ------....---------------- <br /> Contractor's <br /> ------I------------------ <br /> ------------------------ ---------- Phone Contractoi s Name------ <br /> --- - ---- -- ------------------------------------------------------------ <br /> Installation will serve: Residence Apartment House F] Commercial E] Trailer Court E] motpl/Fl Ner 0 P <br /> Number of living units: ---- Number of bedrooms ----L- Number of baths -------- Lot size --- <br /> Water Supply- Public system � Community system [I Private [] Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet. Sand F1 Gravel E] Sandy Loam E] Clay Loam El Clay 11 Adobe El Hardpan F1 <br /> Previous App cation Made: Yes 0 No E] New Construction: Yes E] No E] <br /> TYPE OF JASTALLATION AND SPECIFICATIONS: <br /> Septic tank or cesspool permitted if public sewer is available within 200 fee.fl <br /> Septic A. Distance from nearest well_'*r '--.-__Dista q fro fru a t�ee ji I--- ---------------- --- ----- <br /> ion/9 <br /> -- ------ ------------- Capacity--- - -----r---- <br /> No. of compartments-:------- ----------Size -'g.. ...K __Liquid#depth <br /> lon/40,,-�- F.-Distance to nearest Dispos Field: Distance from nearest well-**------Distance from foundaf' ire Q li e <br /> Number of lines----_---_- -------- -Length of each line--------------!2 ------Width of french--�-_--- --------------- <br /> -------------- <br /> Type of filter materi 4- epfh of filter material-- -- -----------Total length <br /> Seepage Pit: Distance to nearest wefl----------------------Distance from foundation-------------------Distance to nearest lot line_.-----.-._----_ <br /> ❑ <br /> ine---- ----------- <br /> 171 Number of p;ts---------------I------Lining material-----------------------Size: Diameter-----------------.!---Depth-------------------------------.- <br /> Cesspool: Distance from nearest well---------------4Distance from foundation--------------------Lining material------------------------------------ <br /> ❑ Size: Diameter------------------------ ----=Dept k----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------------------------. <br /> ❑ <br /> uilding------------------------------------------ <br /> E-1 Distance to nearest lot kne---------------------------------------------------------------------------------------------------------------------------------------------- <br /> 0 lin W- and/;or r�ir i n g crilk--------------------- - --------- ----- ----------------------------------------------------------------------------------------------------- -t <br /> 41Z -------------------- <br /> -- -- --------- <br /> - --- ------------ - <br /> --- ------------ - -- ---- - - --------- --------------------------- <br /> 4t at- <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, State laws, and rules an re I fl of the San Joaquin Vocai Health District. <br /> gu A�aT o- <br /> ------------- ----- ----------------------------------(Owner and/or Contractor) <br /> (Signed)----- ------------------------- --- ---------- - --- ---- -------------------- <br /> .By:-------------------------------------------------------- -- ---------------------------------------I-------------------------------iTitle')--------------------------------------------- -------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, 6uildings, efc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE -------------------------------------------------- <br /> REVIEWEDBY------------------------------ � ----- - ----------------------•------------.------------------------------------------- DATE ------------------------------------------------- <br /> BUILDINGPERMIT ISSUED----------- ------------------------------------------------------------ ----------------- DATE---------(---------------- --------------------------- <br /> Alterationsand/or recommendations:------------------------------------- --------------------------------------------- -------------------------------------•------------•------------------------- <br /> ­-------------------------------------------------------------------------------------------------------------- <br /> ----------------------------- -------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------- -------- ---------------------------------------------------------------------------------------------------------------------------------I---------------------- ----I---------- <br /> ----------------- ------------------------------ ---------------------I--------- ------------------------------I------------------------------------------------------------------------------------------------------------- <br /> . A2--- -Date.... --FINAL INSPECTION BY:........... ---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 30.0.West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5-9-2M 10-52 Revised W-2100 <br />