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�y APPLICATION FOR SANITATION PERMIT Permit No. <br /> . _ --­-_---_,- <br /> (Complete in Duplicate) S <br /> Date issued <br /> t Application 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 OCA .ION. ��` � --------- = - ��! (� �'l ,—------------------ <br /> --------------------------------------- <br /> Owner's Name " `�' -------------------------------- Phone---- - '' <br /> -------------- <br /> Address �. T r' ---• ----------------- - ------------------ -------- - <br /> Contractor's Name----------- .-�-------------- Phone-- ------ <br /> Installation will serve: ResidenceAT Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: Number of bedrooms Number of baths ---/__ Lot size <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabie��ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan ❑ �, <br /> Previous Application Made: Yes ❑ No New Construction: Yes ❑ N,,J�' <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-------------------.Material--_-----__.-___--_-.--------__------------_____-. <br /> � No. of compartments--------------------------Size----•---------------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well-___-._.______Distance from foundation--------------------Distance to nearest lot line----.--_----____- <br /> � �/ Number of lines-----------------------------------Length of each line------------------------------Width of french----------------- .___------ <br /> Type of filter material-------------------------Depth of filter material----------------------Total length--.-__-_-_-__-_----_.-_-_-----.-_--...__-- • <br /> Seepage Pit: Distance to nearest well__.__-Distance from,f dation----- <br /> --------.Dist/an�e to nearest lot <br /> Number of pits----------/----------Lining materia-Size: Diameter....��-- ------.Depth �� ? ----------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----_-.-----___-----_--___-__-_--__--. <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. • <br /> Privy: Distance from nearest well-----_--_---------------------------------------Distance from nearest wilding-_- --______------___-_---__------____-. <br /> ❑ Disfiance to nearest lot line ------ --------- -- <br /> Remodelin and/or repairin (describe):______�_�_/�_.���...____.__ __________�--- -� <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 la ..and rut a regulations of the San Joaquin Local Health District. <br /> (Signed)---------------�� = ;. •= '--------- ---------------------------------------------------------------(Owner and/orContractor) <br /> By:---------------------­- — ----- y ------------------------------------(Title) _��� 1 r ------ <br /> .(Plot plan, showing siz o Ia , Toca ' n stem ineF lation to wells, buildings, etc., can be placed on revers de). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------------------------------------------- ----- DATE_� <br /> REVIEWED BY ----------- --------- -- --------------- DATE <br /> BUILDING PERMIT ISSUED ------------------------------------- DATE--------- <br /> - - - - ---•----------- <br /> Alterations and/or recommendations----------- -------------- ------ --------- -----------•-----------------------------•-------------------•-------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------•----------------•_------------------ <br /> -----•-----------------------------------------•------------------------------------------------- -----------------------------------------•---------------------------------------------- ----------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- ----------- <br /> FINAL INSPECTION BY-_. '~*�l_'�'_��' ------_-- Date------------------------------- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfree+ 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> �l <br /> ES-9-2M 8-51 Revised W-2100 <br />