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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate( 7 <br /> 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 LOCATION. --------------------------------------- <br /> Owner's Name ----------- ---�--- . Phone-------------------- - <br /> Address---------------------*- !.f2. ------ ------------------------- <br /> Contractor's Name-- ---------------- ::.�l 1`'' hone. <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [❑ Other ❑ <br /> Number of living units: -_-- umber of bedrooms r <br /> --_-- Number of baths . .---- tot size -�.�-���0------------------------- ----- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe eHardpan ❑ <br /> Previous Application Made: Yes ❑ No L!d 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 /> e tic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material------------------------------------------- <br /> No. of compartments-------------------- -----Size--------•----------------------Liquid depth--------------------------Capacity------ --- ------ <br /> i e i <br /> ispos 'Id: Distance from nearest well_-�1_-____Distance from foundation---3Q..----....Distance to nearest lot Irye--�_---___-- <br /> D' Number of lines---.-------f-- ----------------Length of each line-----�Q___..._---_--.Width of trench-r� _-----:---_--__--,...-- <br /> Type o44 <br /> f filter material-� r1 Gr -.Depth of filter material---_,����.-----.Total length--_-��_�-----------------'- <br /> .-. <br /> i <br /> Seep 'P& Distance to nearest well./0110____._.---Distance from foyndation_--.0_-------- <br /> Distance to nearest lot line----------------- <br /> Number of pits------/-------------Lining material--;-• &- kS,Size: Diameter----- ----. Depth--_ 51------------------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-----.------------ Lining material-------------------------------------- <br /> F1 Size: Diameter-------------- ----- Depth------------------------------ --------------------Liquid Capacity --------------------------gals. <br /> Privy: Distance from nearest well-...-___.__-.-----.-_-- ------------ -Distance from nearest building---------------------------------_------. <br /> [❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------••--------------------- <br /> Remodeling and/or repairing (describe)------------------ ---------------------------------------------------------------------- -------------___------------------------------------ <br /> ----------------------------------------------------------•----------•----•--------------------------------------------=---------•------------------------•------------------------------------------------------------------ <br /> •------------------------••---------------------------------••---------------------------•--------•---•----••---------------------------------------------•------------•-•------------------••------------•------------------- <br /> -------- -------------- ----------------------------------------------------------------­----------------------------------------------------••----------------•----------------------------------------------------------- <br /> I hereby certif t at I have pr pared this application and that the work yq�a done in accordance with San Joaquin County <br /> ordinances, State w , and rule a d regulatia s of the San Joaquin Local a th Dist 'ct <br /> 1 <br /> ------- - --------- -.----- -------- ---- --- ------- - <br /> ---------------------- ---------- <br /> igne --------• �----- r <br /> gr• -• --------(Titl ---- ----- - --------- ------------------ <br /> ----------------------------- ------------ <br /> (Plot plan, showig 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 /> -- ---------------------------- <br /> REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------.- DATE <br /> BUILDING PERMIT ISSUED-------------------------- - DATE------ ---- --- �—.- ----------- -------- -- <br /> Alterations and/or recommendations:-- ------ - ------------- -_..-...------•----------------------------------- ------ ------- <br /> -•-•---•--------------------- _- -- ---- - ----- �� ------•----- ----------------------------------•-----•-••---•------------------------------------ <br /> : - _. �- - <br /> - --------------- ------ <br /> FINAL INSPECTION BY:----- ( V- ------------- --------------------- Date------ -_----------------------- s T <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South Arnerican Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California • <br /> Es J-2M 145446 AT.... iz-- <br />