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f�1 <br /> Permit No. ____ll- -- <br /> APPLICATION FOR SANITATION PERMIT - <br /> {Complete in Duplicate} 3� <br /> Date Issued ____--- ______________ <br /> Applica*ion is hereby made to the San Joaquin Local Health District for a permit f ' o struct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. E <br /> JOB ADDRESS AND LOCATION s �` { --------------------- <br /> ---------------- ---------------------------'--•-••-•-------------•------'---------- <br /> Owner's Name_ Phone <br /> Address.. ... ----=--- ----------- -------=----------- ----------------------------------------------------------------------•- ..................................... <br /> Contractors Name --•----------------------------- --­----------------------- Phone <br /> -� <br /> Installation will serve: Residence Apa ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __ .____ 14umber 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 ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe " Hardpan ❑ <br /> Previous Application Made: Yes ❑ NX New Construction: YesX No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: I ' <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' <br /> eptic Tan Distance from nearest well------ Distance from foundation__'_°: _._.__.Material_________ ----------------------------- <br /> No. of compartments----------------------- Size---------------------------------Liquid depth----------- --------------Capacity........................ <br /> isposal 'el Distance from nearest well-----------------Distance from foundation---------------__-.Distance to nearest lot line____-___-__-____- <br /> Number of lines-----------------------------------Length of each line___----------------------------.Width of trench-------------------------c.__------ <br /> Yp p _..- --- ---=----Total length- ---------------------------------------- <br /> --------- <br /> Type of filter material.__--_.___...______ <br /> �� <br /> _______Det o iter materia____._-__:_ <br /> See a e it. Distance to nearest-well ..____._ Distance fr m fo ndation_ !1.__°____.Distance to nearest lot line_-- <br /> Number of pits-__._______`__.____Lining material__ .-Size: Diameter.___ __--------------Depth--- ---------___.___ <br /> Cesspool: Distance from nearest well------------------Distance from foundation---------_____i-----Lining material------------- <br /> ❑ Size: Diameter---------- ----------------- --------- Depth--------------------- ------ ------------------`- <br /> ----- ---Liquid Capacity------------------------....gals. <br /> Privy: Distance from nearest well <br /> ----------_________________--___.__-_____-:.-Distance from nearest building------------------------------------- <br /> ._._. Q <br /> j. ❑I �. Distance to nearest lot line--------- - -- - - ------------------------- ------- <br /> - ----- - -- -------- <br /> Remodelin d/oT—repairing {describe):-- �� '.. ',� = --- ------- ...- � f--� ---------- V <br /> --------- -------•- ----------- -------------------------------------------- -----------------------------------------------•----------- <br /> ----- <br /> ------- - <br /> �' 1 <br /> ------------------------- --------------------------------------------•-----------------•_------------------------=---------------------------------------------...-------------------------•---------------------- <br /> I hereby certify that 1-have-prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Sta "as, and le nd re, uldtibns of the San Joaquin Local Health District. <br /> (Signed) ------------------------------------------------- -----�nree <br /> Owner and/'br Contractor) <br /> e y <br /> BY: r--------------------------------------------------------------- ----------------------(Title) - "'(Plot plan, showing s e of lot, location of system in relation to wells, buildings, etc., can be pi . se side} I <br /> i FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED B6_-----------------------------------------'----- ------------------------------------------------ DATE -------------------------------------------------- <br /> REVIEWEDBY-------------- ---, --------------------------------------------------------------------------------'DATE--.r ---------- '---------•--......-.------• - <br /> BUILDING PERMIT ISSUED---------- ------------------------- <br /> _--------------------- - DATE --fir <br /> ����- <br /> Alterations and/or recommendations----------------------- -------i - - - <br /> --•-------`---------------------------------------•-•------•--------- ---------------------------------------------------•-------------------- •-----•--------------------------------------------------------------- <br /> ---------- -------------------------•----------•----------------------------------- <br /> 4 <br /> ___________________________________________________________________________________________________________________________________________________________________________________________________________________ _ ______ <br /> r _ <br /> Date-—'."FINAL FINAL INSPECTION-BY:...------=`' 1 -: '-- -- ----------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> l <br /> ES-9--2M ; Revised W-2100 <br />