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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issue�__�" <br /> Application is ,hereby made to the San Joaquin Local Health District for a permit to c nsLnct a d install the work herein described. <br /> This applicatjtin is made in complian e with County Ordinar�ee P oo. 549, <br /> JOB ADDRESS A LD TIO ! _" <br /> - �� <br /> ---- --- ------- ----- -- -- - -- <br /> Owner's N e ---- -•--•- - ------------- <br /> T <br /> -----• Phone <br /> --- ------- r <br /> Address_-__ __ ___d <br /> t <br /> Contractor's Name---- _ _-•- - --------- --- ------•- Pho-A <br /> Installation will serve: Residence Apartment House ❑ Commercial [❑ Trailer Court p tel T, Other [] <br /> Number of living units: j--- Number of bedrooms __ _ Number baths J---- Lo t size __(____ _-- ------------------ <br /> Water Supply: Public system ❑ Community system ❑ Private Depth t Water Tableft. ys <br /> Character of soil to a depth of 3 feet: Sand El Gravel E] Sandy Loam Clay Loam [� Clay E] Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No 5?/ New Construction-. Yes No E]TYPE OF INSTALLATION AND SPECIFICATIO�S: r �� <br /> (No septic tank or cesspool permitted if publ)c sealer i available within 2001i3et. <br /> Septic ank: Distance from nearest well__gg._'� _________ ista fr m f nda/A_ <br /> #- ;y-- _-_.Material____'_ _________________ _______No. of compartments ��eL -i-----Size-- - id cl t. th Capacit --------- - r <br /> Dispos 'Field: Distance from nearest ell 40_ s arjce,from fo4ation_ 7`T!_ Distance to nearest lot line __ �� <br /> Number of lines----------- ----1 ----------- Length of each e___•-" �Q-a-r Width of trench--------- --- -- -----------..+ <br /> Type of filter mate3epth of filter mU.eriah __!_$_. __Totaf length___________ __ ___ _ ______-- <br /> ► V <br /> Ilk <br /> Seepage Pit: Distance to nearest well----------------------DistanceJrom foundation--------------------Distance to nearest lot line________________ <br /> ❑ Number of pits----------------------Lining material--- -------------------Size: Diameter-----------------------Depth-.------------------------------- T <br /> Cesspool: Distance from nearest well-----------------Distance' from foundation--------------------Lining material-------__-_-___-________-__:________- <br /> ❑ Size: Diameter--------------------------------------Depth-----------------------------=- -------------------Liquid Capacity_�-------------------------gals. <br /> Privy: Distance from nearest well----------_--------_-----------_---------------__Distance from nearest building-_________-__-_-___-__---______________-_- <br /> ❑ Distance to nearest lot line----------------------------------------------------------------------------------------------- :K <br /> Remodeling and/or repairing (describe)=------------------------------------------------------------------------------------------------------- ------------------------------------------------ <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 /> :_ Owner and/or Contractor <br /> (Signed)-�Voi <br /> ----- --- -t----- �----- <br /> �.. ( / <br /> By:--------------------------------------------------------p�- ------------------------------------------------------------------(Title)---------------------------------------------------------------- <br /> (Plot plan, showing size of lot, loc �' of system in relation to wells, buildings, etc., can be placed an reverse side}. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B - DATE -------------------------------------------------- <br /> REVIEWED BY--------------------------- <br /> -- -- -- ---------------------------------------------------- ------ DATE__ <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-- <br /> Alterations and/or recommendations: - - <br /> +' ^ ' -- _� f ��" ----'-' ------------------ <br /> -------------- ------ ----------- ------------------------- <br /> I - I <br /> ---- <br /> ----------------------< ':� 'C-� __r:;L4_ ...........9'' . --------- , -------------------------------------------------. <br /> 1 s <br /> Ayri� e <br /> FINAL INSPECTION BY:- ----------------- ----------- Date.- �j <br /> a. <br /> USAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> �zrAA, <br /> 130 South American Sire"et � 00 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 />