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a <br /> APPLICATION FOR SANITATION PERMIT Permit No. .-LI.74_:n <br /> (Complete in Duplicate) S ;/ <br /> Date Issued _____ ________ _ ___ <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. <br /> JOB ADDRESS ANQ LOCATION..----' "' 0 ----- �--- -- -----------------------------------•-------------------------------- <br /> Owner's Name - - ---- - -- - --t:---- -- -------------------- Phone---jpZ--r a "• <br /> Address_ <br /> Contractor's Name--------(� ti --------•------- ---------- ---------------•----------------------------•----•--------------------._. Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mofel ❑ Other ❑ <br /> Number of living units: ___/--- Number of bedrooms .---/_ Number of baths I____ Lot size --------------------________________________________________ <br /> Water Supply: Public system E❑ Community system ❑ Private ❑ Depth to Water Table -------- f+. <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 ❑ 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 Tank: Distance from nearest well_________________Distance from foundation------------_------Material------------------------------------------------- <br /> F1 <br /> _____.-____-__.----____..______-__._________-.❑ No. of compartments--------------------------Size--------------------------------Liquid depth-----------------.........Capacity----------------------- <br /> Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line_-__-_________-- <br /> ❑ Number of lines----------------------------------Length of each line-----------------------------.Width of trench.----------------------------------- <br /> Type of filter material--------------------------Depth• of filter material---------------------.Total length-------_--------_----------------_-------- d <br /> Seepage Pit: Distance to nearest well__--------------------Distance from foundation--------------------Distance to nearest lot line__----.._________ <br /> ❑ Number of pits------- -----Lining material___ ------------Size: Diameter----------_............Depth__------_---__.___.____------_.._ M <br /> Ce sp ol: Distance from nearest well-----------------Distance from foundation___________________Lining material-______.__:__..___ �_.__.__.___. <br /> Size: Diameter Dept �? Liquid Capacity_. Y4X-�7`r' als. <br /> Privy: Distance.from nearest well--------------------------------------------_----Distance from nearesf building-------------.___-_------------------- <br /> ❑ Distance to nearestI lot line-- --- q------------------ -------------------------------- -------•---------------------- <br /> Remodeling and/or repairing {describe):------� ------------- - - ------ - -- -- - -------- ,.. ------------------------it <br /> --•------•--•------- ---- --- - - =-------------------------------------- -- - ---.---- <br /> - --------- <br /> r _ <br /> ------------------•- - ---------:--- ---- _ ----- --- <br /> -- <br /> - ------------------------•---_--•------ --•-------------- ---------t <br /> ---------- <br /> I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin <br /> ordinances, State laws, and rules and regulations of"the San Joaquin Local Health District. <br /> (Signed)----------- -------•------------•-------------I------------------------------------------------------------•----------------------------=------------------(Owner and/or Contractor) <br /> By:---------------•-•--.. - -• - # ----------------------------------------------------------_•---------------.(Title)--------------------------------------------------------------- <br /> • - - ---------------------- <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 /> REVIEWEDBY----------------------------------------- - ----------------------------------------- ------------ DATE--- --- --------------------------------------------I - <br /> 'BUILDING PERMIT ISSUED------------------- 0-- - DATE------ -------------------------------------- - <br /> - ------------ <br /> Alterations and/or recommendations: 1-----------------------•-- °---------------------------------------------- ----------•------------------------------------.--------------------------- <br /> ------------------------------------------------------ - i ------- ------------- ----------- ---- - --- <br /> :: -- - -- -- ver <br /> - - - 4 <br /> - - - - <br /> --------------- _-____ -- ----- --------------- --- --A-------------------- - -!.. -- ---------- __:_:-__-- :-_:_ _-:---__--------___.-_:------------------------------- :- <br /> �� _ � . <br /> FINAL INSPECTION BY:. �� ��_­---------- Date----------------- ----------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Streot 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-21M 10-52 Revised W-2100 <br />