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APPLICATION FOR SANITATION PERMIT Permit No. .-If_,�__�____ <br /> (Complete in Duplicate) a y S3 ' <br /> Date Issued <br /> --_-- ----�---- <br /> Application is hereby made' the San Joaquin Local Health District for a permi to construct and install the work herein described.- <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AN LOCATION__ -_ ._ __________ ____ -! <br /> ----------------` '_ __-_ <br /> 11 _______________________________________________ <br /> Owner's Name---- -- --- ----- Phone------------------------------------ <br /> f ---:-- <br /> Address------3F ------------------- -----------_ ----- --------------------------- <br /> r <br /> --- - ------ <br /> Contractor's Name----- -- - ---------- "----- Phone--'- <br /> Installation will serve: Residence @4—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: J?:__ Number of bedrooms._=__ _ Number of baths ___L Lot size ----5�rd r_____Ar --_---------------- <br /> Water <br /> ----.-_ _ .- <br /> Water Supply: Public system [+ ommunity system ❑ Private ❑ Depth to Water Table 7_0 ft. <br /> Character of soil to a depth.:of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe -Hardpan ❑ <br /> Previous Application Made: <br /> ❑ No R:;.- New Construction: Yes [�'`No <br /> TYPE OF INSTALLATION LAND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) <br /> Septic Tank: Distance,,,,' <br /> istance from nearest well-----------------Distance from foundation__-_ _- -------Material_,± ► . ...__. <br /> No. of compartments_____.-2 __-_--__Size_ ' ' _ J±__•__-Liquid depth--_ ____`___ CapacitY____G ��____ \ <br /> ` <br /> Disposal Field: Distance IMfrom nearest well-__________----__Distance from foundation____-4_,2_-._.Distance to nearest lot line -,/Q. <br /> Number'of lines____________ _ Length of each line----- 4.'.--------------Width of trench C � <br /> Type 0i{ter material__------------------------Depth of filter' material-_________-___-__.---- otal length-------.---------------------------------- <br /> Seepage Pit: Distance:to nearest well --._______--------__Distance from.founds+ion_--,, 4....___.Distan e to nearest lot line---4.__------ <br /> Number'of pits--------/-----------Lining material__A3­,%it± ,Size: Diameter___„ .-___.____Depth -01`1-------------------- <br /> Cesspool: <br /> ________________Cesspool: Distancel from nearest well______ _________Distance from foundation-----_--------------Lining material__-_____________.___.____-______- - <br /> F -Size: Diameter-- --------==:--:------ ` = Depth= ___"--__--: ------- - '_.----- Liquid C.apacitY `-_:gals. <br /> Priv Distance from nearest well-_____._____-___ _X.-._1_.-_-_Distance from nearest building <br /> ❑ Distancel.to nearest lot line--------_----------------------------------------------------------------- <br /> Remodeling and/or repairing (describe)__________________________________ <br /> I � <br /> ----------------------------------------------•--•-----------••------••----•--•----•_... •--•--------------•-------•----------------------,----------------z=V-------------------------------------•-••---------------- <br /> II <br /> -----------------------------------------------M-----------------=-----------------------------------•------------------------------------------------------------------------------------------------=---------------------- <br /> I hereby certify that I }lava prepared this application and that the work will-be done in accordance with San Jtaqu4n Coun+y <br /> ordinances, Stat laws, and'rules and regulations of +he San Joaquin Local Healfh District. <br /> (Signed)---- ` - --- _" .=---------------- -[Qwnerean*xoraContractor) <br /> = <br /> i Plot plan, showing size of I t, location of system in relation------ ----------------------------------------(Title)------_----------------------------------------'----------__-'-' <br /> By:-------- <br /> 1 ( p g it y ion to wells; buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> I APPLICATION ACCEPTED BY-------------------------------------------------- --J- DATE-------------- <br /> Ys`, <br /> REVIEWED BY----------------------- -.-------------------- -- ---------------------- ---- DATE------- <br /> ' --- <br /> - - --- ------ <br /> BUILDING PERMIT ISSUED-- --------------------------------------------------------------•------------•---------- DATE.----------------- <br /> ' Alterations and/or recommendations:dations:--------------------=--------------------------•------•-•--------------------------------------------•-----•-------------• --------- ------------------------- <br /> ----------------------------------------------- -----------------------.----------------------------------- ----------------------------------------------------- ---------•-•---••----••----------------. ----------- <br /> -----•--------------------------------------------------•-----•---------------------- -----------------•----- ----------------------------•------ ----------------------------------------•----------------------- <br /> --=-------- ------------ ------- - -1:----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> 9M <br /> F . <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 /> k <br /> ES---9---2M 0-52 Revised W-2100 <br />