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1 <br /> APPLICATION FOR SANITATION PERMIT Permit No. Vescribed. <br /> . .. i <br /> (Complete in Duplicate) sDate Issued -_-- �__-_Applica}ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> This application is made in compliance with County Ordin97 No. 549. <br /> JOB ADDRESS AND CATI N / . -------------- - ,�, .. °t ".- ----- <br /> ----------------------------------------------- <br /> Owner's Name.-- Phone„ ---------- <br /> �.-- -- � <br /> Address--------•-••------------•=-------�-• I�---- -- --• ---••--- - ----- ---- ---- - -- ---•--- -•-----------------------------------...-----•...... --- --------- <br /> Contractor's <br /> - -- <br /> Contractor's Name------------------------------- -------------------------------------------- Phone- ' - <br /> Installation will serve: Residence Apartment House ommercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' <br /> Number of living units- _ ..____ Number of bedroom ./-__ Number of baths _/-___ Lot size -------._ <br /> Water Supply: 'Public system Community system Private ❑ Depth to Water Table eft. NIN <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Ciay ❑ Adobgr Hardpan ❑ <br />*' Previous Application Made: Yes ❑ '' <br /> N V New Construction: Yes V' No ❑ `` <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> '(No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic <br /> Tank: Distance from nearest weIILr.�Distan e�from fgundati n .____-__.Materi <br /> -__Ca a--- ------------ <br /> Disposal <br /> _ <br />,. No. of compartments----p. ._._____-__.__Size .. iquid depth _ p y_____ ____ , <br /> Disposal Field: Distance from nearest well,,,-E .Distance from foundafion� '_'___:'_.Distance to nearest lot line___________ <br /> i. <br /> Number of lines___ ____________________ ____`Length of each line________ __ Width of trench.- <br /> --- <br /> Type of filter material ______Depth of filter material--- ----------- length________ 1 <br />_ Seepage Pit: Distance to nearest well-----------------------Distance from foundation-------------_----Distance to nearest lot line_______.______.__ <br /> ❑ Number of pits----------------------Lining material-_---------------------Size: Diameter------------------------Depth--------------------------------- <br /> Cesspool: Distance.'from nearest,well____--______`__Disfance from foundation._________________ Lining material-------------------------------------- <br /> r. <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 /> 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, ano rules and regulations of the San Joaquin Local Health District. <br /> (Signed)-- ------ ------------------------------ ----- ------------------------------------ = -(Owner and/or Contractor) <br /> B % D+ -------------------------------------------(Title) ------------------ <br /> Y: •--•---- ---- -- -1�' <br /> (Plot plan, showing size of lot, location of system in-relation to wells, buildings, etc., can be pl ced o Zverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------------•----------------------- ------ . 41b- - --------------------------- DATE----------- 1 --------------- <br /> REVIEWED BY------------------------------------ ----- -�------ <br /> -------------------------------- --•- -- -- -------------------------- DATE----- ----------..------------------------------------------ <br /> BUILDING <br /> ----------------------------------------- <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations---------------- ---------------------------------•-------------------------•------------F------ --------.... ......I......I....... ------------------- <br /> --------------------------I------------------------------------------------- <br /> -------------------•------------------------•--------------------•---------------------------- - ----------•--------------------------••-------------------- ----------------------------------------------------------------------•- <br /> -------•-----------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------- <br /> ---------------------------------------------•-- -•---•----------------------------------•------------------- ----------------------------------------------------------------------•---------------------------............. <br /> FINAL INSPECTION BY:.-" --------- !'`'.�.'! �----------- Date---- ---------- .-------------- ------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Streef 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ; Revised W-2100 <br />