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Permit No. <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> Date Issued ____—lex <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. 54 . <br /> JOB ADDRESS AND LOCATION.... -------- <br /> �1 <br /> ------------------- <br /> Owner's Name --• - ------------------------ - ------------------------------------------ Phone__1 ------ <br /> Address.. ------------------------------------- ----------- -- -------- <br /> Contractor's Name------------------------- -------------------------------------------------------------------------------------------------------------- Phone.------------------ <br /> Installation will serve: Residence ;@ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number'of living'units:"_/_'1N&sber of bedrooms ---/-- Numbe � � <br /> Water Supply: Public system ❑ Community system 0 Private [Z Depth to Water Table _#­ft. <br /> Character of soil to a depth of 3 feet: Sand 7 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan p <br /> Previous Application Made: Yes ❑ No 0 New Construction: Yes A No ❑ <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_MO______Distance from founda tion__)?_--_________.Material___________________ ____ ___ _ _ <br /> No. of compartments____-__ `___ -_Size__ _ _ _ _____Liquid depth___.3-_-_C__'..._.___Capacity__ Q <br /> ,y ,W�,y��, y� r, ------ <br /> Disposal Field; DistSfi� i'rom nearest weI!__ _D0____Distance from foundation.__j®____._._Distance to nearest lob line._ _ __ <br /> [� Number of lines__________ ____.__ Length of each line----4- - --------Width of french----2____------------__________ �} <br /> ' /i <br /> Type of filter material _ -___--_Depth of filter material---/'4______-.___Total length____ ____________________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation__-_______--_______.Distance to nearest Iot line----------------- <br /> 1-1 <br /> -- __________❑ Number of pits----- ------Lining material-----------------------Size: Diameter-----------------------Dept h------------------------I <br /> Cesspool: Distance from nearest well-----------------Distance from foundation_.------------------Lining material________-_--______--__.---_- <br /> ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity-------------------------- <br /> Privy: Distance from nearest we41 ________________________ ________•----_-__ - is an e"from"""'nearesfYbui❑ '` r -Distance'to nearest lot I--ane-_-_.---_.-Remodeling and/or repairing (describe)------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------••---------------------------....------:------------------------------------------------------------------------------------------------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 re tions of the San Joaquin Local Health District. <br /> r / <br /> (Signed) * - :_ _[Owner nd/or Contractor).. <br /> By -------------- --•--------------------------401,------------------------------ --- - -- ------- ------- le-----------{Tit )-------------------------------------------- ------------ <br /> (Plot plan, showing size of lot, location of system in relatian 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 /> BTJILDII�"GPER17iiT ISSUED _'---- ----� ...�_ ----- ------ - --- -------- <br /> --- --- ' <br /> Alter dos and/or rec mmendations:._ ___ <br /> � 7 ----AV/-Ac--�----------------- --------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------- -------------------------------------------------------------- --------------------- -------------------------- ---------------------------------------------------------- i <br /> -------------------------------------------------------------------------------- -------------------------------------------------------- --------------------------------------- ---------------------------------- <br /> ------------------ --------------------- ----- ----------------------------------------------------- --- <br /> -------------------------------------------------------- <br /> fFINAL INSPECTION BY: ! � ---------- Date -j ---------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 Soufh American S+reef 300 West Oak Sfree+ 132 Sycamore Sfreef 814 Norfh,"C" Sfreef <br /> Stockton, California Lodi, California Man+eca, California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 <br />