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ti <br /> APPLICATION FOR SANITATION PERMIT `: Permit No. <br /> (Complete in Duplicate) r <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health Disfrict for a permit to construct and install the work herein)described. <br /> This application is made in compliance with County Ordinance No. 549. f <br /> A <br /> JOBADDRESS AND LOCATION------- —7Z = = I--------------------•-------------------------------------•--------- <br /> -- <br /> � ----------- ------------------- --------------------------------------- <br /> - <br /> ---- Phone--•------------------------- <br /> Owner's Name--------- ---- -- - ----- <br /> --•-CAddress---------------------- ---------- ------------------_.. I------------•-"----------------------------------------------------------------------•-------------------------------•------ <br /> Contractor's <br /> ontractor s Name --- ---------=-------------------•-•--------------------------------•------------------- Phone. <br /> Installation will serve: Residence Apartment House ❑ Commercial .❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __j.____ Number of bedrooms _ ___ Number of baths ___j____ Lot _- � _____x____1__ 3__:_`______.___.____-_ <br /> Water Supply: Publidsystem %j� Community system'❑ Private ❑ Depth to Water Table <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ClayE] Adobe- Hardpan ❑ <br /> Previous Application Made: Yes ❑ No 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 /> Septic Tank: Distance from nearest well_______________ Distance from foundation <br /> ____..__._________:Material______.____.__._______________._.__________.___. <br /> ❑ No: of compartments---=-------------- ------Size-------------------------------Liquid depth--------------------------Capacity------------------- <br /> Disposal Fiefd: -Distance from) nearest well ...._.Distance from foundation------------------__Distance to nearest lot line----------------- ' I <br /> Number of lines---.------------------------------Lengfh`of each line------------------------------Width of trench----------------------"__"--------- <br /> ❑ <br /> Type of filter material-------------------------Depth of filter material_-______..___________Tata) length___________________ ------ <br /> Seepage Pit: wDistance tonearest well_..-----_____________Distance,from rfoundatic,n__-_`----____.:._".Distance to nearest lot lir�e---------------- ! <br /> )]'i Number of pifs"--------------- -----Lining material---------.------------Size: Diameter------------------------Dept <br /> 'n�Cesspool: Distance Distance from near st well-W.ah distance from foundation--. ---------Lining material----_.__ -. <br /> Size: Diameter..___. ___ -------Depth_�_ ---Liquid Capacity ..gals. <br /> f { <br /> yPrivy:. Distance from nearest well-______________-------------------- _ ' __Distance from nearest building <br /> ❑ Distance to nearest'.lot line---------- . ------ -----' _ -----�------ --`---------------------- , -------- <br /> . ------ - <br /> 4Remodeling and/or re Idescri � - <br /> t --------------------------------------------- ------ <br /> { ... . <br /> ----- -------- <br /> IL <br /> = --------------•------s-------------- -------r••--•-----...-------------------------•------------------.... ----------------------------------------------------•-------------•-------------•------------ <br /> i <br /> } <br /> I'hereby certify that l have prepared this application and that the work will be done inaccordance with San Joaquin County_ <br /> ordinances, State laws s and rules and regulations of the San Joaquin Local Health District. <br /> �. i E + <br /> 1 <br /> {Signe .. = � ----- --------- -------------------------------------------------•-- {Owner and/or.; ontractor) <br /> d). - k <br /> 1 <br /> ------- -- -- ----------------------------------------- •--- Title-_-----------_--------------------------"----------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> 9 <br /> FOR DEPARTMENT USE ONLY , <br /> APPLICATIONACCEPTED BY-------- '_= ---------- --------- --"---------------------------------------- DATE--------- �-------------------------------------------- <br /> REVIEWED BY - ------ ---- i DATE j-------------------------------- <br /> BUILDINGPERMIT ISSUED---------------- = --- ---------= --- ------------------------------- DATE---------------- -----------C9-------------------------- <br /> A rations and/X,recommen do -•------ --------------•-----=---------------......- -- •--••------`--�--`4--- --- <br /> ------ ---- <br /> 1 - - � --•----- ---------------- <br /> ---------- <br /> ------ ---- �. = ; <br /> . •---------•----•------------ <br /> --------------------------- - ------ --------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------- <br /> 2 <br /> ------------------------------ -------- --------------------- --------------------------: --------------- -------- ----------------------------------------------------------------­--------------------------------- <br /> FINAL INSPECTION BY:. `= == `ti"m . —"D"ate _�- --�-�-� --------------------- <br /> R w SAN JOAQUIN XOCAL 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 /> ,f„_-,, <br /> ES---9-2M Revised W-2100 <br />