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APPLICATION FOR SANITATION PERMIT Permit No. ________ _____ i <br /> (Complete in Duplicate) <br /> Date Issued _--- 5 <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 /> t <br /> This application is made in compliance with County Ordinance No 549. <br /> JOBADDRESS AND CATI N----••-•---- �- --------�8 ----�--1-�-- -- --------------- ------------------------••------------- <br /> Owner's Name ! / �'1?''-?! : � r- .r_' :• '" ---------------------------------- Phone-- �' �----------••- <br /> Addre s� <br /> !(rCJ.... - �y� .y <br /> Contractor's Name--------------------------• ---- - .- Phone�_ _ - <br /> Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ /Motel Other ❑ <br /> Number of living units: __ __ umber of bedrooms � Number of baths _/-__ Lot size __- -----------`---------- <br /> Water Supply: Public system ❑ Community system•❑ Private Depth to Water Table Gft. : <br /> Character of soil to a depth of 3 feet: Sand El Gr'av'el ElSandy Loam ❑ Clay Loam ElClay ❑ AdobHardpan ❑ j <br /> Previous Application Made: Yes ❑ No New Construction: Yee No ❑ <br /> 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 well__._ _ -_-Distance from foundation__ ._-4Material __ ____ ___________ _________ <br /> y z <br /> No. of compartments----`1---------------Size- -_ (4VAI -Liquid depfih_- ----- Capacity-- Q-- ---- <br /> Disposal Field: Distance from nearest well__,��__---_Distance from foundatio -r, Width e tt neo est lot rline--- <br /> --------------- <br /> i Number of lines <br /> --____Length of each line <br /> Type of filter materia�______Depth of filter material___�q.��___Total length____________ _ ___ <br /> ---------•------- <br /> Seepage Pit: Distance to.nearest well__ _._.___Distance rom f ndation____r .____.-.Distance to nearest Iot li �,____.__-__.. <br /> l Number of pits.-----f--- ------Lining materiae---Size: Diameter------ --------------.Depth____-- -- p_ <br /> - -- <br /> Cesspool: • Distance from nearest well_________________Distance from foundation--------------------Lining material---.--------------------:-'�---__ <br /> ❑ ---Depth-------------- ----------- -----------Li Liquid Capacity - als. <br /> S+ze: Diameter---- ------------•-------- - --------- - q p tY- - •----------------- -- 9 <br /> Privy: Distance from nearest well_______________________.-__._____._.__________-"'Distance from nearest building----------__--___________ <br /> ❑ Distance to nearest Iof'line------ __ - ------------ --------------------- ----------------=----a-- -----------I--—-------------------------- --- -------- <br /> Remodeling and/or repairing (describe)-- -----------------•----------------•------------------•-------------------------•---------.-------------------------- <br /> ------- -------- -----------•-----------------------------•---------:-- <br /> ------------------ <br /> ------------------•----------------------------------------------------= <br /> - ' F ____________________ ___________________________________________________________________________ <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 I and rule %andegulatio he San Joaquin Local Health District, <br /> (Signed) f - --- ----------------- ---`------------------------------------------------------------ - -----(Owner and/or Co actor <br /> • ---------------------•----------------(Title ---- ------- ------------- - -- <br /> (Plot plan, showing size of t, location of system in relation to wells, buildings, etc., ca`n be p on reverse side]. <br /> FOR DEPARTMENT USE ONLY 1 _ <br /> 4. :�• DATE- - 1 _._ ----------------=-------- <br /> APPLICATION ACCEPTED __ .._ _ _.__ _- _- <br /> -- <br /> REVIEWEDBY------------------------>----------------------=.-:------------------------..------------------------------------------------ DATE--------------------•-------------------------------------- <br /> BUILDINGOERMIT-ISSUED---------------------------------- ---------------------•--------•----------------------- ------------ DATE----------------------------------------------------- <br /> Alterationsaril/or recommendations------------------------------------- ------------------------------------------- ---------------------------------- --------..-•-•---------------------------- <br /> ----------------------------------------------------­------------------------------------------------------- <br /> ---•-------------•------•------------------------------------•--------------------------------------------------------- -------------------------------•-•--------------------------•-------.---- --- <br /> ---------------------------------------------------------------------------------------------------- ------ <br /> ----------------------------------------------------------------- <br /> FINAL INSPECTION BY:.--' �--------�- ------ -;- ��-- -----=--- Date----- ---- ---------- - �-�- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfraet <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-4-2M Revised W-2100 <br />