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� 1r <br /> APPLICATION FOR SANITATION' PERMIT Permit No. <br /> " • (Complete in Duplicate) �`/ <br /> Date Issued ___� __ ___5__ , <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 Or - ante No. 549. i <br /> JOB ADDRESS A DLO ATIO --- ------------ ------- =' E <br /> _ . '► <br /> --- - ----------------- = ------------- ------------- ----------------------------- Phone_ <br /> Owner's Name___-_ ___ _ <br /> , 5 p --------------------------------------------------------------------------------- <br /> Address t ------------ <br /> Contractor's Name-- -•- - --------- Phone <br /> Installation will serve: Residence/ �partment House ❑ Commercial ❑ Trailer Court ❑ Motel <br /> 4 Other [I E <br /> Number of living units: __1__-_ Number of bedrooms _2__ Number of baths __;f___ Lot size _____f_ _ -_____x__ _t�__O-------------- <br /> Water Supply: Y I : Publics stem E] Community system F] Private E3XDepth to Water Table,-�4?ft. �1 <br /> Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Lo�PN'o <br /> Clay Loam ElClay ❑ Adobe Hardpan El <br /> Previous Application Made: Yes ❑ No New Construction: Yes ❑ a <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if pubic sFwer is available within 200 feet. <br /> Septic ank: Distance from nearest well--_ __-Distan e fr fou ation___S O__-.Materia___cv��� <br /> No. of compartments-------------- t----Size Liquid de t P Y f <br /> Dispos Field: Distance from nearest well ___t+.Distance from foundation ff _ _ _!____.Distance to nearest�l-o# iJ7�___--_°_°_i_' <br /> INumber of lines___________' ___ ____- Length of each line--____:_!__Z_ _= Width of trench---_i_Y__�_ *_______________ <br /> Type of filter mate <br /> --- _�--Depth of filter material---------- _ _ Total length____- -- V- --------_________________ <br /> Seepage Pit: Distance to nearest well-----------------------Distance from foundation-------------------.Distance to nearest lot line----------______ <br /> ❑ Number of pits----------------------Lining material------------- ---------Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_____--_-.-__________--__-----._____- <br /> .❑ Size: Diameter_ -- --------- ------Depth------- ----- ----- ----Liquid Capacity------------ -------------gals. <br /> _ - „�- - <br /> ��.ui - --- <br /> Distance from nearest well ____________ ____ .__. _ _-______Distance from nearest building_._________-------------------------------- <br /> Privy:❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------- -------------------- <br /> Remodeling.and/or <br /> -------------------Remodeling.and/or repairing (describe):-------------- ----------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------ -----•----------------------------------- <br /> -------------•------------------------------------------------------------------------------------- ------------------------------------------------------------------ <br /> -------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f <br /> ordinanc s, State laws, and rules and regulation�of the San Joaquin Local Health District. <br /> r � (Owner and/or Contractor) <br /> (Signed)- i 'o' <br /> BY:-- -- --- --- /-------------- - <br /> ---------- -------------------------------------(Title)---------------------------------------------------------------. <br /> ----- <br /> (Plot plan, showing size of lot, location of sysism 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 ._. - DATE ------------------------------------ <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------------------------- DATE---- <br /> Alterations and/or ecommendations:_________ ______ _ ,_-----_._E___�_________- _ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> = ----------------------------------------------- ------------------------------------------------------------ ----------------------- ----------------------------------------------------------------------------•--------- <br /> -.-------------------------------------- ///// 7/------------------------_---=_-- ----- <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 /> }*1-9-2M 9-51 Revised W-2100 <br />