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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) a <br /> lY Date Issued ---- -- <br /> plication 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. 549. <br /> JOB ADDRESS AND LOCAT ON ------- <br /> ------------------------------- <br /> Owner's Name._l-.-t-- ---------- ---------------------_-- ----- - Phone------- <br /> Address_.. — <br /> -' <br /> Contractor's Name.----�f-�......-- ---- � -------------------------------------------- Phone-_1:7.574 a. <br /> Installation will serve: Residence &-'-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> t, r <br /> Number of living units: _-_ __ Number of bedrooms I... Number of baths ---/--. Lot size -_-_-7--d-x--_ -_ --r---------------------------- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sandi Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No Q' New Construction: Yes ❑ No [T"" } , <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 well-----------------Distance from foundation-------------------Material------.-_------.------.-----------.------__--- <br /> ❑( ,' No. of compartments------ ------ -----------Size--------------------------- -- Liquid depth--------------------------Capacity--------------------I <br /> Disposal Field: Distance from nearest jel .--.�__O _Distance from foundation-------� .Distance to nearest lot line-Number of lines------------ - ---- .-. - _Length of each line___-------I ________.Width of trench.---- ... -_--:_- <br /> Type of filter material-_-/�a-_-�_Depth of filter- al-------�-S'-,--Total length___-----.-- �__,-__---� <br /> Seepage Pit: Distance to nearest well.---_-`���__Dista from fou datio _-------I, _---:Distance to nearest to ine ----- <br /> Number of pits______.-___-_-__Linin ma riaL-___-_-- <br /> ------------------------------ <br /> g GAG Size• Diameter-- Qeptn--- --- --------- <br /> Number <br /> Cesspool: Distance from nearest well----------------- istance from ation_____.---_-------_..Lining material--._--_----.- _-____---____ --_---. <br /> ❑ Size: Diameter--------------------------------------Dep ----------------------------- ----------------------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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Sta laws, and rules nd regulations of the San 2Jou,,n Lacal Health District.Si nedOwner and/or Contractor <br /> - ----- --------- -------- -------------------------- ( ) <br /> B {Title)_ -.__-- <br /> Y• ----------- <br /> --------------------- ---- -- --- -- -- ------- ------------------------ <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-------3-,I � ----------------------------- <br /> REVIEWEDBY--------------------------- - - -------------------- DATE------ --------------.....----------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- r <br /> Alterations and/or recommendations:_------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------•---.­--- ------------------•------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> --------- ------------------------- -------------------------•-------t ----------------------------••----------------------------------•------------•---•----------•-------------------------------------------- <br /> FINAL INSPECTION BY:------v •. ---•------ ------------ Date.---------- J ----------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfreef 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M i0-52 Revised W-2100 <br />