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s APPLICATION FOR SANITATION PERMIT Permit No. .__�... <br /> �] (Complete in Duplicate) <br /> "`TTT Date Issued-_/__ __1_ _____,� <br /> (�1 <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 /> ---- ------ <br /> ----- -- ------ --------------- <br /> Owner's Name--------------------------------------------- ------------------------------- Phone-- <br /> Address-.----------- --------------............ Q^'+. <br /> Contractor's Name---------------------------- Phone _ ...... _k_A-�------- <br /> ••--••-•--------•--•-••---------------------------- <br /> -------------------------- <br /> Installation will serve: Residence,Apartment HouseCommercial Trailer Court E] Motel Other F]Number of living units: ,__Number of bedrooms E]Number of baths _ Lot size ------ I _T___ -___ .��r _-______ <br /> Water Supply: Public system .. Community system ❑ Private ❑ Depth to Water Table <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 ❑ No ❑ +. -ir.�� r„� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> tic Distance from nearest well_________________Distance from foundation-------------------- <br /> Material------------------ --------------------- ---•• [ s. <br /> No. of compartments Size Li fujLl`depth------------ - - ---- --- Capacity---------- --�- QW <br /> Dispo al Field: Distance from nearest well._I' M�Distance from foundation''__i� --------------Distance to nearest <br /> Number of lines----------t----------------------Length of each line_____'_-___._____.Width of trench_._=1_______� <br /> Type of filter material-__-pi Depth of filter material----.___-j_�.s�-----Total length__!��-------------------------------- <br /> Seep ge Pit: Distance to nearest well------dPK11 __Distanc fr$�� fo ndation-----/w�._______-Distance to nearest lot • e__._ ®_�~ <br /> Number of pits______________________Lining mate ria l_�''_'*''k _.Size: Diameter___._r _ _E t.___Depth_._ --------------------- <br /> Cesspool: <br /> _Cesspool: Distance from nearest welL_______________Distance from foundation--------------------Lining material--------.__-___-----.------.__._____-- <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity-.--------------------------gal . <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------- <br /> F1Distance to nearest lot line----- --------------------- ---------------- - •---------------------- ---------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------- ------ ----------------------------------------------------- <br /> ---------------------------------- <br /> -----------------------------•-------•-----------------•-----------------------------------------------------------•-----•------.....------------------------------------•-•----------------------------------------------­ <br /> ------------------- <br /> -- <br /> --------- ------P, nd <br /> ---------•-----------------------------------------------------------•----------------•------------------------------------------------------------------------------------------- <br /> I hereby cI have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, St, rules d regulations of the San Joaquin Local Health District. <br /> 9 q <br /> ------------- ------------ ---- -------------------- - ------------ ------ -- - -- ------ -- - <br /> (Signed) ----------- ------- �� Contractor) <br /> By:---------------------_- ---•-•------------------------------------------------------------------------------------------------(Title)----�'-1-4i, 4�---------------------- <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 <br /> --------------- - -- <br /> REVIEWED BY--------------------------------------------- ---------------------------------- "f ------------------- DATE `-�--- !:; ---- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------- --------- •--- ----------- DATE-------------------------- <br /> Alterationsand/or recommendations--------------------------------------------------- --••--••--------------------------------•--------------------------••--------------------------------------- <br /> ----------------------------------- -------------------- •------------------------------------------------------------------------------ -------------------------------------------•--------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> A3 � <br /> FINAL INSPECTION BY----------------- / _�?------- Date-------------------- --- ----------------------------- <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 I0-52 Revised W-2100 <br />