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APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> (Complete in Duplicate) 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 Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION--- -- _ ---------------------- ----------------------------------------------- <br /> Owner's Name------- a -- -------+--------- Phone------------------------------------ <br /> Address-----------•--- --------------------------------------------------------------------------- <br /> ---------------- - <br /> Contractor's Name------------------- ------------------- Phone----------------------------------- <br /> Installation will serve: Residence artment House F] Commercial F] Trailer Court [IMofa ❑ Other ❑ � <br /> Number of living units: ____j___ Number.-of bedrooms ____I_ Number of baths j____ Lot size ---------- ------------------ <br /> Water <br /> _________•______ <br /> Water Supply: Public system ommunify system '❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Q Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ew Construction: Yes '- <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 1 <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) \ <br /> ?,lo pfic ' : Distance from nearest well_________________Distance from foundation_---_____________-_.Material_______________---____________-_____No. of compartments--------------------------Size------- ---------------Liquid depth_-------------------------Capacity----------osal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line_---_____________ <br /> ❑ Number of fines-----------------------------------Length of each line------------------------------Width of trench-----------_----------------------- <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> ❑ Number of pits----------------------Lin• material----------------------Size: Diameter---------- -----------� --------- - , -------------t i <br /> Cesspool- Distance from nearest well___ __ ____ dat _ _. min ---- -- --1-- --. <br /> Size: Diameter----------------------------- pf --------- ----- ---------- �'}-`f iqui apa i gals. <br /> f -- - -- <br /> Privy: Distance from nearest well------------------------ ------ istance a t`b in -----------.-------------•----------_---- t <br /> ❑ Distance to nearest [of line------ ------------------------------------------------------------------ ---------- <br /> Remodeling and/or repairing (describe):-------- ---- = ---------- ----•-------- ------- ------------- <br /> ------------------------------------------------ ----------•--••--------- ------------- ------------------ <br /> ----------------------------•-------------------------------------------------------------------•------------------------------------------------------------------- <br /> I <br /> -------•------------ - <br /> I hereby certify that I have prepared thi pplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and re ulatio s of the San Joaquin Loca! Health District. <br /> \. <br /> ------- � ________________(Owner and/or Contractor} <br /> (Signe ---------- <br /> B --------------------------- ----------------------------------------------------------------------------------(Title)---------------------------------------------------------------- <br /> (Plot pian, 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 /> REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE----------------------------------------------•------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations----------------------------------- ------------------------------------------------------------------------------------------------------------------------ <br /> ---------------------- -----------_--------- ---•--------------------------------------------•----------------•-•--------------------- ------------------------------------------------------------------------------- <br /> -------------------------------- <br /> ------------------------------------------------------------------------ ------------------------ - ----------------------------------------------------•----------------------------------- <br /> i ---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- <br /> FINALINSPECTION BY:----------- ------------------------------------------- Date---- ---- j ------------------------------------------ <br /> r 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 /> 9-2M B-51 Revised W-2100 <br />