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b• APPLICATION FOR SANITATION PERMIT <br /> Permit No. ......_,- <br /> (Complete in Duplicate) Date Issued <br /> Applica+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 Ordinance No. 549 <br /> JOB ADDRESS AND LO ION---- - �'�— ----- ------- ------------------------------------------- <br /> Owner's Name_ ----------- -------- ---------------- I---.--------------------------- Phone- -- - <br /> Address____ __ <br /> ----------------------- ---------------- --- --------•----... <br /> Contractor's Name------------- *------ - -- -1------------------------------------------ ------------•--- Phon �.:,�,2� <br /> Installation will serve: ;Residence Aparfinen ouse E] Commercial ❑ Trailer Court F1 Motel Other. ❑ <br /> Number of living units: _- _____ Number of bedrooms ./ <br /> _ Number of baths -____ Lot size _d' ,/ -"x ----------------------- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ff. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy loam ❑ Clay Loam ❑ C1ay ❑ Adob� Hardpan E] <br /> Previous Application Made: Yes E] NOX New Construction: Yes/ `` No E]TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Ta k: Distance from nearest welV-----------------Distance from foundation--------------------Material__-________-__---______--._______-_--______,_- <br /> e. No. of compartments-------------------- ---_size------­-----------------------Liquid depth----------------- --------Capacity--------------------- <br /> Disposal 'el Distance from nearest well_________________Distance from foundation--------------------Disfance to nearest lot line_______...__.____" <br /> Number of lines------------------------------------Length of each line------------------------------Width of french.-------------------------------- <br /> Type of filter material----------_--------------Depth of filter material-----------------------Total length----------------------------___________-- <br /> i .,Distance to nearest'well_�✓+ _. Distance from f ndation__ �j (f1 <br /> Seepage it: ___ g'________.Distance fc nearest lot line___. <br /> y� Number of pits------ ------------Lining material Size: Diameter_. ` <br /> Ce�ss'ppool: Distance from nearest well-----------------Distance from foundation___________________ Lining <br /> ❑ materia. <br /> l_-_----_----________________-___ <br /> Ie: Diameter------ - ----- --------- -----.Depth---------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance <br /> from nearest well-________________________________________________Distance from nearest building-------------------A__-_______-.____---._. <br /> ❑ Distance to nearest lot line_"_____: -------------------------------------------- 'F <br /> Remodeling nd/or repairing (describe :_-_ .... -- <br /> y, ! , -- ----------------------•----•-•----------- <br /> -------------•-------•- -------- <br /> -------------------------------------------------------------------------- <br /> -- <br /> J- --------•------------------- ----- ----------------------------------------------•-------•-----------•-------:-- •---------------•--------------------------------------•---------- <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 reg .'.ns of the San Joaquin Local Health District. <br /> (Signed)--- -� <br /> ------ ------ - - � ---- �-----� r Contractor] <br /> . -(Owner a-n-d- <br /> By: , /+ -------------------------- ----------1------------ ----------------------------(Title ---- -------- <br /> (Plot plan, showing siz f lot, Iota Ion of system in relation to wells, buildings, etc., can b ted on reve a sid <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B ---------------------- -•-------------------- -- DAT *�.t _.------------- ..r. / <br /> t { DATE-- ° <br /> REVIEWED'BY----- ------------------- <br /> --11 ----•- ----- ----------- <br /> BUILDING PERMIT ISSUED---- ---- ----•- ---------•-----------------------------•------------ DATE-----'L` <br /> Vx --------------- <br /> Alterations and/or recommendations-=---------------------- ------------------------ ---------------------- �� <br /> ---" <br /> '� - <br /> '' <br /> ---------------------- --------- <br /> -------------------•-------------------------- ---------------------------------------------------- <br /> ----------------------- ----- ------�-----1-'A <br /> ---- --- - -------------------------------------------Date ----------- <br /> SAN <br /> -------- ----- -- - ---- -- ----- <br /> ------------------------- <br /> --------- <br /> FINAL INSPECTION BY:. ---------- ---------- . �� � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street Soo West Oak S+reet 132 Sycamore Street 814 North "C" Street <br /> t <br /> Stockton, California <br /> Lodi, California Manteca, California Tracy, California <br />