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APPLICATION FOR SANITATION PERMIT Permit. <br /> �1 (Complete in Duplicate) <br /> Date Issued --- ---___"-- <br /> TA plica4ion is hereby�de to the San Joaquin Local Health District for permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> s { r <br /> l <br /> ?I? 7l .�-./ � --- <br /> JOB ADDRESS AND OCATION--..___.-" . <br /> `' - <br /> Phone <br /> . <br /> Own <br /> ers Name ---------1 -----------••-----------•--------------••-- --•------. --------`----­-------------­1.---------------- <br /> Address <br /> ---•-----------Address f ---------------X U -------------- ----- Phone--_/� <br /> Contractor's Name.---- <br /> Installation will serve: Residence [El—Apartment House ❑ Commercial ❑ Trailer Court [jMotel ❑ Other [I <br /> I pp ' a g �x----- "z-------------- <br /> Number of living units: 1...__ Number of bedrooms _Number of baths ---/"--- Lot size __......__.__ ... <br /> Water Supply: Public's stem Community system ❑ Private ❑ Depth to Water Table��__ ft.` , <br /> PP Y� Y �- <br /> Character of soil to a depth of 3 feet:t Sand ❑ Gravel 171 Sandy Loam El Clay Loam El Clay I--] Adobe R_ Hardpan ❑ <br /> Previous Application Made.: Yes ❑ No Z_ New Construction: Yes ❑ No_ i <br /> i <br /> E TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tankor cesspool permitted if public sewer is available within.200 feet.) _ <br /> 3 .r. .,,* . .. <br /> Septic Ta k:( Distance from i nearest well_..._-.----- --_Distance from foundation__._...-...___-----Material.............."-......-.---.____...__......__..- <br /> p❑ ��� of compar#tments. - Size----------------- -------------Liquid-depth-h---}---------- ------- Capacity---------- ------ <br /> � � A ,. ; <br /> pis oral Field 4 istance from nearest well.....---- Distance from foundation..-_.s,"._.__'.....Distance to nearest of line................" <br /> 0 'Tlu er of lines:--------`-------------------------Length of each line Width of trench <br /> T�of filter material---------- -------Depth of filter material----------------------Total length----------.--------------------=--------- 1n <br /> _r <br /> �.... I . .,� F <br /> 5eepa.ge Pit: Distance to n ares# well-----�1�7��Distance from f°undation____� __.. Dista cte, to nearest lot line................. <br /> 'Number of pits--------�....__ Lming materia►_L`_'.. -.f .L� ze: Di meter......._ <br /> Deptn <br /> ----------- <br /> � <br /> 4 i <br /> Cesspool: Distance from nearest well---------------'Distance from foundation__...__-------- Lining material_.........__...._.--"."...-.___....._ <br /> Size: Diameter ----------------- -- <br /> - Depth-----------------------------------------------------Liquid Capacity-------- -------------------gals. 3 <br /> Priv Distance from nearest well-------------------------=----------------------Distance from nearest building------------•---------------------------------- <br /> ---------.--•-------------- � <br /> Y - - <br /> Distance to-nearest, <br /> lot line'._-"__"' <br /> Remodeling and/or re } -------•----- --------=------------•------------------...-----------'"-"-' <br /> pairing {describe):.................:_-- •-"""""":"'""""""-- <br /> --------------------------------------- -------------= -----.---------...------•--------------...----------------------------------------------------------------- <br /> ---••-------•------------------------------------------------------------•--------------------------------------•-----; <br /> r1 =------------------------ <br /> Fhereby-certif I have prepared this application and that the work will-be done in accordance with San Joaquin ,ounty <br /> ordinances, Sta laws,'an rules and regulations of the San Joaquin Local Health District. `� <br /> /��L = ----- -------------------------------------------------- ------ er and/or'Contract <br /> (Signed)---- i orl <br /> � -• -� --_ {Tit e). <br /> `' <br /> BY: - - V <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 /> APPLICATION ACCEPTED BY-------- --------- ----- - -----------`"--------- J DATE._ `_ <br /> REVIEWED BY------------`------------ -' --- DATE c .----------------------------------- <br /> BUILDING PERMIT ISSUED------------------------ - -------------------------------------------------- D TE-------------- --� <br /> �!"------ <br /> Alterations and/or recom endations:------ ---------- ----•-------•- - .,... <br /> - ----- ------------------ <br /> - ----------------------------------------------------------••----- <br /> --------•------- --- - <br /> �` <br /> ---•- ----•---- -------------------- - <br /> -------------------------- <br /> ---------- <br /> = �. <br /> -- <br /> -- <br /> - - --- - --- -•---- - ------- ----- Date--.- j-~ -J--- - - ------ <br /> I -f------------=------------•--- <br /> FINAL INSPECTION BY:-+y_-0 � . ----- _ ---= <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--4-2M Revised W-2100 -�- <br />