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J APPLICATION FOR SANITATION PERMIT Permit No. .......... ... <br /> (Complete in Duplicate) ,2-1s S Y <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 Ordinanc No. 549. <br /> JOB ADDRESS AND <br /> �+LOCATION-------l--�o-- `- _ � = ----------------------------------------------------------------------------- <br /> Owner's Name---___;; '---- --------------------------------------- ----- -- --- -- Phone-- -~. ------ <br /> Address - ------------------------_----------------------------------------------------------------------------------•---- <br /> v : <br /> ------- <br /> Contractor's Name----- � --- <br /> ' J4 <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: j---- Number of bedrooms Number of baths _-/--- Lot size ---- 5--_ _ -r - ------------------------- <br /> Water Supply: Public system �ommunity system ❑ tPrivate ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[+Er1qardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes L 1VO ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: , <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> 4eap __Tlank: Distance from nearest well------.-I-----Distance from foundation--------------------Material -------------__----___---_.-_------._--------_. <br /> No. of compartments--------------------------Size----•-------------------------Liquid depth--------------------------Capacity--------- ------------- W <br /> D's .sal Field: Distance from nearest well-----__-_r------Distance from foundation--------------------Distance to nearest lot line----------------- a ' <br /> ' Number of lines---------I <br /> ------Length of each line------------------------------Width of trench----------------------------- --- Al <br /> Type of filter material- —�-}_____.Depth of filter material----.--_.---_---------Total length___-------------------------------------- <br /> Seepage t: Distance to nearest well_ ---------------Distance from foundation____f d___--_.Distance to nearest lot line---_- --------- <br /> 41. . <br /> Number of pits-------f------__--Lining material_ Size: Diameter_---- -$_ ------Depth__._-a_S_'___________________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation.-------------------Lining material_-_.__--.__.-------.-----_---_-_-----. <br /> ❑ Size: Diameter------------------ ------------------De th--------------------_- ---------_Liquid Capacity <br /> p --------------- - - q ------------------ ------gals. <br /> Privy: Distance from nearest well-------------------------.-----------------------Distance from nearest building------------------------- --------_-----. <br /> ❑ Distance to nearest lotfrli,ne---------------------------- -------------------•----------------------------------------------------•---------------------------------------- <br /> N�/! <br /> Remodeling and/or repairing (describe):------ ------------------ ---- -------------------•---------------------------------------- ------------------------------------ <br /> ---------•-----•--•--------•-----------•----------------------•-------•--------------------------------------•--------------------------------------•------------------------------------------------ ----------------------- <br /> -- <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 aws, and rules and regulations of the San Joaquin.Local Health District. <br /> (Signed --------------------- <br /> }---- ---- (O no and/or Contractor) <br /> sy:..- ------- -- ------------------------------------------(Title)-- a � s' --- <br /> (Plot plan, showing size of lot, location of stem in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- t ------------------------------- <br /> REVIEWED <br /> •-------------- DATE • _ _ -.... <br /> REVIEWED BY----- ------------------------ - ------ DATE <br /> BUILDING PERMIT ISSUED--------------------------------------------------------------•------------------------- ------------- DATE------------------------------------------------------------ <br /> Alterations and/or recommendations:---------------------------------------------------------------------------------------------•----------- •----------.-._..•----•------------------------- <br /> ----------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------•----•-•--------•--•-------------- ------- ---------..-._--------------------------------------------•---------------------------------------------------------------=----- <br /> ----------------------------------------------•--------------------------­­-­1------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------- ------- ------------------------------------------------- ---------------------- ----------------------------------------------•------------------ <br /> FINAL INSPECTION BY:. - / Date.. 1--- -+,,.�..-. ••-------------------- <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 /> r ES-9-2M Revised W-2100 - <br /> .r <br />