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U <br /> APPLICATION FOR SANITATION PERMIT Permit N <br /> (Complete in Duplicate) 7/ r/ <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 Ordinance o 49. <br /> JOS ADDRESS AND OCAT ON... ( � ----------------------------- <br /> ----- ---- ---- -- - - - <br /> I .. <br /> i <br /> Owner's Name---------------- ------ ......---- ---------------- --------------------------------------- Phone--------=-------------------------- <br /> Address-----------Address.-----------•-•----- �. �. �� � �------------------------------------------------ -- ------ ----------•----- <br /> t 1` <br /> '�--------------- Phone_ <br /> Contractors Name-----:_ --(�-.F- 0-- ___ ---_-- Q. _­14-------.�f�`---- -- +_ _ <br /> r � <br /> Installation will serve: 'Residence,�Apa�tment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> i /� Y / <br /> Number of living units: -- -- Number of bedrooms :j_�"Number of batf`Ns Z---- Lot size ---UIQ---A\-----�_!_..a------------------------- <br /> Water Supply: Publicisystem �oimrnunity-system'0�- Private-[]—Depth to Water Table 3a ft. <br /> Character of soil to a depth of 3;feet:' Sand ❑ Gravel ❑ Sandy Lo�XEJ <br /> m ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes,❑ No ❑ New Construction: Yes <br /> { �, <br /> TYPE OF INSTALLATION ANDjSPECIFICATIONS: s •� <br /> (No septic tank or cesspool permitted if public sewer is available within 284 feet.) <br /> Septic Tank Distance from nearest well-----------------Distance from foundation-__---------_______-Material--_------________-_--------_-__------------------�I <br /> ❑� No. of compartments----------- --------------Size-------------------r- Liquid depth <br /> q p ------Capacity----------------------- <br /> Disposal ield: Distance from'nearest well_________________Distance from foundation--------------------Distance to nearest lot line--_--__--______ <br /> ❑ Number of lines----- -------------------Length of each line------------------------------Width of trench--------------:-------------------- <br /> Type of filter material-------------------------Depth of filter Material------------------------Total length_---__---_--__-_-- -_ _ �l <br /> Seepage Pit: Distance to nearest,weh.�#,_1f----------Distance. fr �fo�ndat.ion__��__._..___.D't nce to nearest lot line-- ---------- <br /> D <br /> --- ►I <br /> Number of pits--- ---------------Dining material--- <br /> Cesspool: <br /> Diameter-_- -------__-____---Depth_____ _ _-__- <br /> Cesspool: Distance from nearest well---i------------Disttance from foundation_------------------Lining material------------------------------------- <br /> Size:Size: Diameter - -----De th---------------- - --- --- --- -----Liquid Capacity ------ -------------gals. <br /> Privy: Distance from)nearest well _ <br /> __________ --------------------------------- _ <br /> ---Distance from nearest building____ __-__.--_-_-____----.-.-_-_---___.-. <br /> ❑ Distance to nearest lot line---3----------------------------- ---------------•-----------------------=--- -• ------ <br /> ..,,. ---- <br /> Remodeling and/or repairing (describe):----------------------------...---------••--- --------•--------•---------`------------•----••-------------------•---------•----....----------- <br /> --------------------•-------------------------------•-•-----------------------------------•----•-•----------------------------....--------------------------------------•---•-------------------------._.. <br /> 1 <br /> --------------------------------------- --------------------------------------_ <br /> hereby certify thattl have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws; and r'ul s a d regulations of the"San Joaquin Local Health District. <br /> 0 8 D 6494,441er.an or Contractor <br /> (Signed).------- ------ ------- ------- ------ . A,l`'c.L ) <br /> a_ - .-......• <br /> 3. Tale <br /> Plot plan, showing Size ----- - ---- ------------ = (Title) <br /> Y• <br /> ( P g 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 /> REVI EW ED BY------------------------------------------ "°p_ -t�--�-:Y-------- <br /> - ------ ------- ------------------ DATE <br /> BUILDINGPERMIT ISSUED----------------------- - - --------------------------------------------------------- DATE------------------------------------------------------------- - <br /> Alterationsand/or recommendations:-----------------------------------------------------------------------------------------------------------------___------••-------------------------------- <br /> ----------- <br /> . <br /> ------------------- <br /> --------------------=--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> i <br /> ---------------------------------------------- <br /> FINAL INSPECTION- 13Y �----Vc � <br /> -- - ----------------------------- 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 B-51 Revised W-2100 <br />