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/ ` U A <br /> APPLICATION FOR SANITATION PERMIT Permit No. ........................ <br /> (Complete in Duplicate) Y) 5 .. <br /> Date Issued -- - ------ <br /> Applica+ion is hereby made to the San Joaquin Loca! Health District for permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AN L CATION . . .... <br /> Owner's Name--------- --- - -------------------------•--- = Phone <br /> Address--------------------------- --------------------- -------�---------------------------------------------1----------•-•-•--.....-- ----------------- <br /> Contractor's Name---- -------------------------------------------------- --- ------ Phone----------------------------------- <br /> Installation will serve: Residence E5111kpartment House ❑ ..Commercial ❑ Trailer Court ❑- Motel L] Other E]__X__ <br /> Number of living units: ______.;Number of bedrooms Number of baths I---- Lot size ____ ._. _..Z __________________________ <br /> Water Supply: . Public system Community system ❑ .Private ❑ Depth to Water Table _______ ft. <br /> Character of soil to a depth of 3 feet: Sand 171 Gravel ❑ Sandy LoVNo <br /> Clay Loam E] Clay E] Adobe [�]Hardpan L]s <br /> Previous Application Made: Yes E] No11' New Cons+ruction: Yes ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted 'f public sewer it available within 200 feetr) <br /> � r , <br /> Septic ank: Distance from.nearest well_ . _ Dista c fr fo�n�dation_Ip"___.___.Mate i�l____ ___________________ <br /> No. of com artments_..___,_-_ , f <br /> t p I ����C Size . Liquid ----?"----------- CaPacitY <br /> Disposal'Field: Distance from nearest well 4441)istance from foundati n � Distance to nearest lot l}n�___- <br /> [v� Number of lines__________ _ _ _ ___ _______ Width of firench_.___ <br /> �FtiA_ttC1D Length of each line <br /> of filter materi .._ p r( <br /> e th of filter matena2_-____�_ _...___._..Total length__________�_k-0-----________..,. <br /> Seepage Pit:` Distance to nearest well_ n <br /> ._.__________________Distace from foundation--------------------Distance to nearest lot line----------------- <br /> ❑ Number of pits----------------------Lining material------------------------Size: Diameter----.------------------Depth_..__...____-____________------ <br /> Cesspool: Distance from nearest weld-----------------Distance from-foundation___________________.Lining material—.___________________.____________ <br /> Size: Diameferl............................ -------De th----------- ---. --- -- - - ----Liquid Capacity-.--------------------------gals. � <br /> Privy: Distance from nearest well------,,___ --------_---------------_------------ Distance from nearest building__-----___.__.___.___-_ ----------------- <br /> N <br /> ❑ istance to nearest lot line------------------------------ <br /> Remodelingand/or or re air;n des s <br /> ...................... ------ ----- -•=------------•-------------- <br /> z <br /> -------------------------------- ------------------ ---------------------------------------------­­------------------------------------------------------------------------------------------------------------------------- <br /> I <br /> ------------ •-•---------------.......-...._..---------------------=------•-------•--•--•----.-----------------------•----------•-------.-------------------------- <br /> I•hereby certify that I have prepared this application and +hafxfhe work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regul tions, of the San Joajuin Loc."ealth District. <br /> ' (Signe ) -{Owner and/or Contractor] <br /> (Title) ------- <br /> (Plot plan, showing size of lot, locatr ion of system in'rela+ion to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> -�I .. <br /> APPLICATION ACCEPTED BY- _-_ DATE ----------------------------------- <br /> "411 BY------------------------------- -------- ---- ------- - --_- ----- ----- ----------------------- DATE--�--------_----------------••------•--••----------. <br /> BUILDING PERMIT ISSUED---------- -------- -------------------------------------------------------------._ DATE.. �� <br /> Alterations and/or recommendafions----- ---- ------- ---- •----•---.,,......._...--•------------------•- --------•------•- <br /> ......._ <br /> d <br /> --.----•-•-•------------- ----------------------------=-------------------------------- ------------------------.-----------------------------------------------------------------.................................----- <br /> r --•-•-----•-----------------•------------•----•---]-••-------- ---------------------------------- :-------.•...----------------------------------------------------------------- --------------------------------- <br /> ----------------•---- ------------- -- } -- - <br /> FINAL INSPECTION- BY............- -- --------------- - -- ------ Date... �ZG=•.f ------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES"-9-2M 145446 PTwppo 12-54 <br />