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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued <br /> Applica4'ion 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 O dinanc No. 549. <br /> JOB ADDRESS D LOCATIO r <br /> _5 <br /> Owner's Name---- - ----- ----••---•-- -- - ---•-------------------•------------- <br /> r ------- ------------- ----------------- --- ---------------------- -------------- Phone.-------------- <br /> ------------ .-. ._� �_ _ <br /> ' -- ••------------- <br /> Address •- <br /> Contractor's Name--- ---•-•-- ----------- -- --------•--------------------------------------------------------------------------------------•--------- Phone <br /> Installation will serve- Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [] <br /> Number of livingunits: _ umber of bedrooms I <br /> �---- �. Number of baths ._______ Lot size <br /> Water Supply: Publici system mmunity 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 �ardpan ❑ <br /> Previous Application Made: Yes No <br /> PP ❑ New Construction; Yes No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted,if public sewer is available within 200 feet.) <br /> Septic "ank: Distance from nearest well._ __ _ Dista frorr� foun ation__LV__-._.____.Mat <br /> No. of com artments_.._ �..X�J�7_:-.___Liquid �epth__- __ --.____,____Capacity__-_ ---� a r <br /> p /� Size y s. <br /> Dispos I'Field: Distance from nearest well"-- -- ! _ _______ <br /> j __ _..._Distance from foundation_ _ ____ Distance to nearest lot li ------- <br /> Number of lines________ ___._. Length of each line_______:._ <br /> -- -- g _a Width of #ranch._-_-__�____ <br /> T e of Filter mater of �-} f------------ <br /> Yp -+ D.epth of filter material------- -- --------Total length-------_----f:_ --[1__ _______---- <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. E <br /> Privy: Distance from nearest welt-----------------------------_---------_---------Distance from nearest building <br /> ❑ Distance to nearest lot line------- ------------------ -------------------------------•------ <br /> Remode- g a /or repainn�dles it a-- -------------------------------------------------•----------------•----------•-------------------------------------------------------------------- <br /> 4, %0 - - r!� -------------- --------- <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 and regulations of the San Joaquin local Health District. <br /> {Si ned !J�/ - __ -�L <br /> 9 {------- -------------- ---- �'iA�l�-------------------------- --- --------------------- - -------------------- ------- -----------{Owner and/or Contractor) <br /> By:------------------------------------------------------ -----------------------------------------------------------------------------(Title)------------------------------------------- - ------ --------= s <br /> (Piot 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 /> APPLICATIONACCEPTED BY- -- ----------------------------------- ---------- --------------------------•------------- DATE -----•----••------ -----------------•----------•---- <br /> REVIEWEDBY - -- - --------------­­­----- ---------------- ----------------•----------------------- DATE___1? ------- <br /> BUILDING PERMIT ISSUED---------------------------------- ------------------------------------------------------------------ DATE----- '- <br /> Alterations and/or. recommendations-------------- ----------- --------------- ---------•-------------•-- <br /> ...................•--------...---------......I---------------------- -------------------------------------------------------------•-----------------------------------------••---------------.-------------------- <br /> ---------- <br /> -----•------------------•----------- ------------------------------------- -- ----------------------- ----------- --------•------------------------------------------------------------------------------------•-•------------ <br /> --------------------------------------------------- ----------- ---------- ---------------------------99--------------------------------------------------------•------------------ <br /> FINAL INSPECTION BY:.--- ---- Date._-__l_._ .2 f ` <br /> --------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 306 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5-9-2M 14S-6 aTWUU. 12-54 + <br />