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APPLICATION FOR SANITATION PERMIT Pettit No. -- -J`- ------- <br /> U" A (Complete in Duplicate) Y <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit tb construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> kJOB ADDRESS AND L ATkON_____ _ __ �_-_ ___ _--------------------------------------- ------------------------------------------------------- <br /> Owner's Name - ------ ---------------------------------------------- Phone 7_244_0 <br /> Address '%s .r-�--`-7----------- -------•------.-...._ ', -- <br /> 3 <br /> Contractor's Name '--------`.r..' == Phone <br /> ---------------------------------------------- ---- - ---------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of living units: ________ Number of bedrooms ________ Number of-baths ________ Lot size ------S_ 0__ __z_L_O---------------------- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ___:____ ft. <br /> F s <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 rbf 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 /> I 1d r No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- <br /> l <br /> Disposal Field: Distance from nearest well- + __.Distance from foundation_J_!�_-___----_ idtn of trench____�_el�.._.______-______-- <br /> Type of filter material__---------Depth of filter material___ .�r-______Total length------2; ©----_ <br /> ----------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundat <br /> ion--------------------Distance to nearest lot line___:____________ It <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-------------- ------------------ <br /> Cesspool: Distance from.nearest well_________________Distance from foun a_f',cn-___:__________f___.Lining material-_______________ f <br /> ❑ Size: Diamete----------- - -------------------Depth--------------- --- -----------------'------=------I_iquid.,Capacify------------- --------------gals. <br />{ Priv Distance from nearest well---------------------------------- - Distance from nearest building <br /> ❑ Distance to nearest lot line__________----------------------------------------------- <br /> Remodeling and/or repairing (describe):------'�� 0 -------------- <br /> -------------------------------------- ------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------ ----------------------- <br /> --------------------------------------------------------------------------------------t ;--•-------•--------------------------------------•------------------------------------------------------------------------------ <br /> ------------------------------------ <br /> --------------------------- ------------------------- ------ -------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby cer ' y th I have repare this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Sta la and ru andr lations of San Joa- in Local Health District. <br /> (Signed)---- ------------- ------ ---- ------ --------------- _ -------- ----------------------------°---------------------------------------------(Owner and/or Contractor) <br /> B _(Title)_ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- ------ - -------- - ----- ----- ----------------------------------------- DATE----------------------------------- <br /> REVIEWED BY ------- ------------------------------------ DATE__ _"_ ,_ . <br /> BUILDINGPERMIT ISSUED-------------- --------------------------- --- --- --- ---- -------------------------------------- DATE---------- <br /> Alterations -------------`-S--- <br /> ------------------ <br /> and/or recommendations------------------------------------------------------------------------------------•---------------•----------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------- ---------------------•---------------------------- ------------------- --------•------------------------------------------------------------------------------------------•-------- <br /> S <br /> FINAL INSPECTION BY:. Date_ G - <br /> �.. <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 8-51 Revised W-2100 <br />