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APPLICATION FOR SANITATION PERMIT Permit No.--Z---5_!_-._-- -__ �- <br /> J` (Complete in Duplicate) 3, / <br /> Date issued.__s ____ <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. 544. <br /> ' -- -=-------- _ <br /> JOB ADDRESS ALOCATION__ --------------------------------------------------------- <br /> Owner's Name-.-. <br /> ____!_ __� _-__'_z__ _ _ <br /> Phone----_---� : <br /> :..----- - - -— -- --- - -- ---- -- -- ----------�------------------- - ------------------------------------ - ---------------- <br /> 1 Address-- .. - -- ------- ---- ----------------- r <br /> -Contractor's Name-- ----------------- ------- -----------------------------------------------•------------------------------------------------------------- Phone----------------------------------- <br /> r Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑} Other ❑ <br /> Number of living units: ______ Number of bedrooms -- NumVD <br /> _baths --1____ Lot size __ _ -_ - l'�__ ___________________________ <br /> Water Supply: Public system.-❑ Community system El Private pth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam ' Clay Loam E] Clay E] Adobe �ardpan E] <br /> RPrevious Application Made: Yes E] No [New Construction: Yes [ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: v <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.)/ <br /> Septic ank: Distance from nearest well__ ___-.Dista q from fo ation___ __n <br /> 11 Mat I--� �1. 'I rr� <br /> ! No. of compartments________ Size_ _ - __-Liquid dept _______ - <br /> --- *--- -- �---- <br /> I Disposa Field: Distance from nearest well-05 Distance from foundation __ -'________Distance to nearest I,gt <br /> Number of lines____ ` ` Len th of each line_ ----- ______ _ Width of trench______' - ______________. <br /> ' - g q <br /> Type of filter materials- _- i/),�P Depth of filter material---------�-�-------Total length--------�-�t�---------------------- <br /> 1 Seepage Pit: Distance to nearest well_.______________,__--Distance from foundation_____________ <br /> --------------------Distance to nearest lot line_________________ <br /> ❑ Number of pits-------------- ------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- <br /> i Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material_____________-___-__--------___-.__._. <br /> i <br /> ❑ Size. Diameter--------------------------------------Depth ------------------------- ----Liquid Capacity--_,-- ------gals.. <br /> l�iiv Distance from nearest well_______________ ------------_Distance from nearest building_______________-_ .---------------------- <br /> re <br /> __________________. <br /> [] Distance to nearest lot line-------------------------------------------------------------••--------------------------•-------------------------------------------- --- <br /> C x � <br /> Remodelingand/or repairing (describe)---------------------------------------- --------------------------------•-••----------•--------------------------------------------------------------- <br /> -------•------•----------------------------------------------------------------•-•---•--------------------------- ----------------------------------------------------------•-------------------------------- <br /> n <br /> 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 /> (Signed) f � _ ---------- ------ -------------------- ------------- ------{Owner and/or Contractor) <br /> By:----------------------•---------------------------------------------------------------------------• --------------------------------(Title)--------------------------------------------------------- <br /> --------------------------------------------------- - = <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--� ------==•----------------------------------=---`--------------•---------------- DATO�------------------------------------------------- <br /> REVIEWEDBY----------------------------- - � - --------------------------------------- ----------------- DATE----% 3 ---••--------- ------------- <br /> BUILDING PERMIT ISSUED ---------------------- ------- DATE- f,��•---------------------------------r---- <br /> 9 Alterations and/or recommendations:--------------------------------------------------------- <br /> l --------------------------------------- ----------• ----- -----------------=-- -----------------=----- -----------------------------------------------------------1­__._1_.._1­__­------ <br /> ------------------------------------- <br /> s. xt„ � ��- ----- `` -- ----- ---- --fit= -------- <br /> _________________________ _______-___ ______ __ _ �__________________ <br /> f � ---- <br /> FINAL INSPECTION SY:_ -�7---- ---i-------------- ----------- Date------------ --�-----'-�"----�-------------- --- e <br /> 3 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ! 130 South American Street A 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 8-5$ Revised W-2100 <br />