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APPLICATION FOR SANITATION PERMIT Permit No.---_a__7l-- <br /> (Complete in Duplicate) � Q�—,>�3 <br /> -OFDate Issued O.____v-....______. <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 County Ordinance No. 549. 74 <br /> JOB ADDRESS AND LOCATION _ -�---- - ---- <br /> Owner's Name------------------------------- --------_- - -- ----- ------------------------------------ <br /> - <br /> ------------------------------------------------------•------------------- •----------L2-----n -e--------------------------.....------------------------------------------------- <br /> Contractor's Name----------------------- --------- -- ------ ---------------------------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Resiclence�;, Apartment House ❑ Commercial ❑ Trr/ailer Court ElMotel <br /> nE l Other El <br /> Number of living units:I------- Number of bedrooms __ ___ lumber of baths L____-. Lot size _________ <br /> Water Supply: Public system ❑ Community system ❑ PrivatelEr 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 ❑ No)Z—New Construction: YesX,No ❑ L <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ` <br /> (No septic tank or cesspool permitted if public pwer'is:aL.eilabl within 200 feet. i <br /> Septic Tank: Distance from nearest well __Z- Distanc from fou tion__._- --x_..Material--I--._ . _:__4_ ------ <br /> No. of compartmeAs_.__�-- _._.._-Size__ P` _- - - -_Liquid depth------ ____.Ca�,acity_--�',�` ___t " <br /> Disposal Field: Distance from nearest well__,5�_---Distance from foundation_---__ _ _!___.Distance to,nearest lot line_____ , <br /> p <br /> Number of lines------------ Length of each line- ___°'_-. Width of french i <br /> Type or filter material i_" ;'--} - Pqp+h of filter material-__- _ __.Total length----------- _____________________ <br /> 1!. <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot Jine----------------- <br /> n Number of pits----------------------Lining material-----------------------Size: Diameter------------------.----Depth--------------------------------- <br /> Cesspool: <br /> ------------------------------ <br /> Cesspool: Distance from nearest well-----------------Distance 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 /> Remodelingand/or repairing (describe):------------------------------------------------------------------ ------------------------------------------------------------------------------------- <br /> ----------•----------------------------------------- •----------------------•------- <br /> ----------------••--- ------------------------------•--------------------------- <br /> * . <br /> - -------------•---------------------- <br /> t �.)k t <br /> 11 <br /> -------------------------------- =-- -------- ---------------------------------------- <br /> 1 hereby certify that I have prepare his application and that the work will be done in accordance with San Joaquin Cou'nty, <br /> ordinances, t laws, an rul s an egul tions of a SanJoaquin Local Health District. <br /> (Signed -- -- ----- ------ - ---- -- ---------------------- ------------------- ---------------------(Owner and/or Contractor) <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 /> APPLICATION ACCEPTED BY -------------------- DATE-------- ' � �� --- -------------- <br /> REVIEWED BY--------------------------------- ----------- - <br /> ------------------------------------------------------------------------------- DATE----------------------------------------------c..----------- <br /> - <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------------•--------------------------------------- DATE----------------------------------------------------------- <br /> Alterations and/or recommendations:--- ---------------- ---------------------------•-----------•------------------------•--------------------------•---------------------------------- <br /> ------------------------------------- ------------•-----------•-----------------------------------------------------------------------------------------------•--------- <br /> ------- - -- ------ ----- ------------ -------•--------------------------------------------------------------•---------------------------------------- <br /> FINAL 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 /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M I0-52 Revised W-2100 <br />