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r <br /> � APPLICATION FOR SANITATION PERMIT Permit No. __-- ---------- <br /> [Complete in Duplicate] q� S�� <br /> Date Issued ' .3_..__/-[ <br /> Application is hereby made to the San Joaquin Local Health Dis+rict for a permit to cons+ t�nd in"s#afie work herein de r e� <br /> This application is made in compliance with County Ordinance No. 549. <br /> R6-ApDRE55 AND LOCATION.--- , --------------- - �------------ <br /> Owner's Name ` ' Phone -� _ <br /> Address — - ° ------------------•--------------------�---------------------------------- <br />{ <br /> Contractor's NameU ---------- Phone/Tj � 1 <br />` Installation will serve: Residence jo Apartment House ❑ -Commercial ElTrailer Court ❑ Motel ❑ Other 04 <br /> Number of living units: ________ Number of bedrooms __2__ Number of baths I--- Lot size --------F O.C'IA-4�_____________________ <br /> Water ,Supply: Public system ❑ Community system '❑ Private V Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand N Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ i <br /> Previous Application Made: Yes ❑ No New Construction: Yes b ] No ❑ .r <br /> j 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 welf_1�yistance from foundation__ ��Material__IGr_-a�r�u1 -- <br /> IL No. of com artmeni-s____-A---______-_ Size___ ----Liquid depth �---------------- <br /> Disposal Field: Nlumberofolirtesearesr wAll- c��1��C}istgance from foundation--Z ._----W'�thcofttrenches+ I�lin�_ <br /> .tel Ii <br /> ,� Len th of each line_,_ ------_ _-____--__-- ti <br /> Type of filter mate rial__�.__�O_r�`__ epth of filter material_______ - _��____Total length______7j- ____ ---------- <br /> Seepage <br /> __ _ <br /> Seepage Pit: Distance to nearest ___Distance from fo dation__ . -___.Distance to nearest lot Ii e d <br /> ❑ Number of pits-- -------------Lining material-- Size: Diam ter_----_-------- ------Dep ------------------- <br /> Cesspool: Distance from nearest weft_________________Distance from foundation--------------------Lining malarial-------------------------------------- <br /> F1Size: Diameter--------------------------------------Dep+h------------------------------•`--------,------------Liquid Capacity-----------------------------gals. LAI <br /> Zoo- <br /> Privy: Distance from nearest well___ __ ______ _____________________Distance from nearest building___.__/�c� --r______. <br /> s ❑ Distance to nearest lot line----- �-+f <br /> Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------------------------------- ----------------------------- <br /> 1 <br /> -------------------------------------------------- - --------------------------- --------•-------------------------------•---------------------------------- ------ <br /> ------------------- <br /> 1 ------- <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 /> I' Si ned --------------(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 /> F EPARTMENT USE ONLY <br /> ;s <br /> APPLICATION ACCEPTED BY------- ---- ---- -- - ---- -- <br /> DATE-------- $ <br /> 1 REVIEWED BY---------------------------------------------------------- <br /> ------------------ -------------------------------------------- DATE a <br /> BUILDING PERMIT ISSUED------------------------•----------------------------------------------------------------------------- DATE <br /> -------------------------------------------- <br /> Alterations and/or recommendations-------- ----------------------------------- --------------------------------------------------I——------------------­------ <br /> 1 ---------------•-------------------------------------------------------------------------•----------- --------------------------------------------------------•------------••----------•----••--••---------------------------- <br /> ----------------------- <br /> FINAL INSPECTION BY:,.-. .. ....:. Date-------- _ ------------ <br /> _ •` <br /> SAN JOAN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak S+reef 132 Sycamore Street 814 North,"C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy,'California <br /> —2M 8-51 Revised W-2100 <br />