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APPLICATION FOR SANITATION PERMIT Permit No. __ -_- _ - _._-- <br />.f�" (Complete in Duplicate) <br /> Date Issued <br /> 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 Ord' ce . 549. <br /> JOB ADDRESS AN LOCA ION_.1�__ _ L ---------------------' <br /> -- - - ----------- ------- --- ------ - -------------------------------------------------------- <br /> Owner's Name----- ` ---------- --�-- e ----------------------------------------------------------- ----------------------------- Phone------------------------------------ <br /> Address...­­........ <br /> --------------`------- -- -------- <br /> Address--•-••-••-----.rl� <br /> Contractor's Name---- = r Phone- --4- tic------ <br /> Installation will serve: Residence//„p rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __-.C___ Number-of bedrooms Number of baths f___ Lot size _ Q___-_ <br /> a Water Supply: Public systemommunity system-E] Private ❑ Depth to Water Table,4`'Oft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ -Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ar pan ❑ <br /> Previous Application Made: Yes ❑f No ew 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 /> Sept- Tank- Distance from nearest well________________Distance from foundation----.---------------Material____~_____..____________________.._________- <br /> No. of compartments--------- --------------Size--------•-----------------------Liquid depth--------------------------Capacity----------------------- <br /> is osal Fie Distance-from nearest well_____ _______ _D'stance from foundation--------------------Distance to nearest lot line__--_____________ <br /> Number of lines-----------------------------------Length-of each line------------------------------Width of french----------------------------------- <br /> Type of'fiiter material---------------------------Depth.of_fi1fer.material-----------------------Total jength-------_---------------------------------- <br /> Seepage <br /> ______________--_______________-- <br /> See a e Pit: Distance to nearest well _ Disfanc'elrom foundation___ <br /> /--:�` Distance to nearest lot line____ <br /> Number ofits:-!./ <br /> ---f_____ _ ___Linin material_ _._----_�_ _ Size: Diameter---2,._ ._.._..De th__ _____ <br /> Cesspool: Distance from nearest well-____________ Distance from foundation___________________Lining material <br /> material_ <br /> _.__---.___--___-__._-_-_-_-_-_-_•_--__g__a__l_s_ <br /> ---- ' ------ �— <br /> .. <br /> - Li uid_Ga acifiY--------=-==----❑ Size: Diameter___' <br /> Privy: Distance from nearest well---_---------------------------------___$-------Distance from nearest building------------------------------.__.-__.___ <br /> ❑ Distance'to'nearest lot line---------------------------------- ----- <br /> T <br /> Remodeling and/or repairing (describe)------- - -- ----- ----- -------------------- -- <br /> � i - - <br /> -------------•--...._......__....-----•----------=----=-------- -- --- - _ - ---- - •-__ -- - - ........ r-----------^--------------''-- <br /> ---------•-----•------ ,-------•---•------------- - -----------------•---------------•--- -- .......... ---- - ---- <br /> - --------------------------•---------•---•------------------------------------ <br /> ---------------•--------• -------------------------------•----------•--•-.-•------------------v---•---•-•--------------------------------------------------------------------------------------------------- <br /> I hereby certify that l have,prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, laws `and rules pd regulations of the S n Joaquin Local Health District. " <br /> (Signed ---•-- i ------- ��er Contractor) <br /> ------------------------------------------ <br /> ------ <br /> BY•----- --------- ------�- -��-r__-th--- --------'----------------------------------------- <br /> •-------- • - ---------(Title)-- ------------- ----- -- --- ------------ <br /> (Plot plan, showing size of Iot, location of system in-relation fo,wells, buildings, etc., can be placed on reverse.side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED.BY--------- ------------ ---- ----------------------- <br /> ----------------------------------- DATE------ <br /> -- - <br /> REVIEWEDBY-------------------------------------I------- -- ---- ----- - ----------------------- ------------------- ------------- DATE--------- ------ <br /> BUILDING PERMIT-ISSUED--------------------------- DATE 7- <br /> Alterations and/or recommendations: --------------- ------------------------------•-•-------------•----•------------- �---I--------------- <br /> -------------------------------------------------------------------------------- --------------=---------------------------------------------------------•--••--••------------•--------------------------••-------------- <br /> 1 <br /> ---------------------------------•-•---------------•--------- = -.------------------------------------------------------------------•---- ------•------------------------------------------------------- <br /> ----------------------------------------------------------- <br /> t <br /> F1NAL INSPECTION BY---------------=----------------- --------------- - -- ==--- Date-=- --✓---�----------------------- -- -----------------•---- <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street I 300 West Oak Street 132 Sycamore Street 814 North "C' Street <br /> Stockton, California 1 Lodi, California Manteca, California Tracy, California <br /> t- <br /> l E5-9-2M Revised W-2100 <br />