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APPLICATION FOR SANITATION PERMIT Permit No. a�--- ------- <br /> 6 <br /> (Complete in Duplicate) Date Issued _ --1------ -�— <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and infill hew work <br /> her <br /> described. <br /> f,This application is.made in complian4clenth os�n�ty Ordin ce No. 549. ( �� 00 <br /> JOB-ADDRESS AND LOCATION.. _____________ ____ <br /> E 1 <br /> Phone--- <br /> ----- - - ------------------- <br /> Owner's Na /J ------ ----- v <br /> , I= -------------------------------- <br /> Address <br /> Contractor's Name--- --- Phone------------------------------------ <br /> me <br /> will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ M//ot ] Oth r _❑ t <br /> J--- <br /> Number o baths . __ Lot size ____I:1_ ---- - _ - ---- <br /> Number of living units: J--- Number of bedrooms <br /> Water Supply: Public system ❑ Community system ❑ Privatep�.Depth to Water Table .------- ft. <br /> PP Y <br /> Character of soil to a depth of 3 feet: SPP and Gravel [I San Loa�No <br /> Clay Loam El Clay E] Adobe Hardpan [� <br /> Previous Application Made: Yes F] No [ New Construction: Yes [+ ElQ) <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public ewer is available within 200 feet.) <br /> Septic ank: Distance from nearest well____ _______Distanc o fgu�da 'c�7n_ _-_- <br /> f ---------.Mate 'a� -------------- --- <br /> -- Size�F_ _Liquid d th---------�"---------Capacity <br /> No, of compartments______________ rr�� �� � �'�- <br /> Dispos If Field: Distance from nearest w �.�Jistance from foundatione__1� ---_- ---Distance to nearest to <br /> �0'�/ Width of trench_______________ <br /> Number of lines------------ -�- +'�--------- - -Length of each line_ -__--- fj----- �---------•------ <br /> Type of filter materi - --�?[` epth of filter ma#erial-------�-- ------.---Total length------- -` -----•--------- <br /> Seepage Pit: Distance to nearest well____------------------Distance from foundation-------.------------Distance to nearest lot line__________-_-_-. <br /> ❑ Number of pitsLining material-----------------------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 building---------.-.______.________.. _ <br /> ❑ Distance to nearest lot line------------------------------------------------- -------- ------------------------------ <br /> Remodeling and/or repairing (describe)------------------- ---------•------------------------•-------------------•--------....... <br /> ------------­­ --•-------------•-------------------------- -- <br /> --------------.-.--------••--•---------------------------------•---------------•- ---------------• -------.. <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 laws, and rules and regulations of the San Joaquin Local Health District. <br /> A <br /> t�4 '� R__._ --. <br /> Owner and/or <br /> (Signed) Contractor <br /> BY=----------•---------------•--------------------------------•---------------------------------------------------------------------(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_12 "------------------------------------------------- <br /> REVIEWED BY--------------------------------- <br /> DATE---?, ------------------------------------------------ <br /> BUILDING PERMIT ISSUED----------------------------- -- ------------------ -------------- -- <br /> ------- DATE---------�-•----------------------------------- <br /> ----------- <br /> Alterations and/or recommendations:------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> n� ----------------------------------------------- - <br /> -------- ---------• ------- --------- ----------- �----�----- ----------------------------------------------------•----------------------------------- <br /> ---------------------------------- <br /> -------------- ------------------------------------------ <br /> -------•------------------------------------------------------------------------------ <br /> FINAL INSPECTION BY:"-------�---`------------------ Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 134 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-21aD <br />