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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued __-. '# - -� <br /> Applica+ion is hereby made.to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This applicat' n ' ma in/�/(p�///',Banc th C rdinance No. 549. <br /> dei ' ' _ -4 <br /> JOB ADDRESS AND OC <br /> ATION_? .�i--Lc� s. f � ��,/ � 1� Y . _. l`------- <br /> Owner's Name-------- --=------- � <br /> --- -- <br /> Phone <br /> --------6 l <br /> ---------------------•--------------- <br /> -.6 <br /> ---------- f-j?--4,­6,7 <br /> f_ <br /> ?-4,6 <br /> Contractors Name---- ------�� 'f------------------------------------------------•----------------------- Phone. .. <br /> I nV-f s0 <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Pg-len"'", , <br /> Number of living units: ______ Number of bedrooms -------- Number of baths ________ Lot size --- Gp - ------------------------- <br /> Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ®--'New Construction: Yes ©-"No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) E <br /> Septic Tank: Distance from nearest well _�1'---Distance from foundation__.--1--CA.......Material---- C---------------��-----fi r--- <br /> .- /� �*- -- 69 opacity >_G�p_- ' t- <br /> No. of compartments__________ ____ Size___ _ Liquid clep�h__ <br /> Disposal Field: Distance from nearest welL__ r'.d--_.�-Distance from foundation__ - ____..__.Distance to nearest lot line______ � � <br /> Number of lines____________ _-tf_-_-- ---Length of each line,. ~�idth of trench.____r _ __��---------------- <br /> ©' ---Total length----- _ _ <br /> • Type os filter materiai_____C-�&___Sc^'-Depth of filter materiaL___.__�--�____ <br /> Seepage Pit: Distance to nearest well-______---------------Distance from foundation--------------------Distance to nearest lot line_____.___________ <br /> ❑ -------Size: Diameter---------------- ---Depth-------------------- <br /> Number of pits----------------------Lining material-----------__--- - <br /> Cesspool: Distance from nearest well-----------------Distance from foundation----------------.-__.Lining material--- --------------------------------- \ <br /> ❑ ---- Depth---------------------------- ------Liquid Capacity------------------------•---gals. <br /> Size: Diameter--------------------- - <br /> Privy: Distance from nearest well__-----------------------------------------------Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot line------ -------------------------- ----- ---------•------------------------------------------------------- c� <br /> Remodeling and/or repairing (describe):.._.... -- <br /> ------ <br /> ______ •-----------------•--•---------------•-------------•------------------------------------------------•--------•---------•------•------------- <br /> I hereby certify that I have prepared this application and +hat the work will be done in accordance with San Joaquin Courrly <br /> ordinances, laws, and rules and regulations of the San Joaquin Local Health District. <br /> r� <br /> (Signed) f �( ,er and/or Contractor] <br /> ` -------�-----"�-=-��------------------------------------- <br /> -------------------- ----------(Title)------ - --------- <br /> By:----/'--- -- ._ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FORDEPARTMENTUSE ONLY ° <br /> t_ �'_•r�v-•_--''�� DATE / •---- ------ <br /> APPLICATION ACCEPTED BY___ 1` <br /> - v----E- ----�--------- - <br /> REVIEWED BY--------------------------------------------------------------------------------------------------------- <br /> DATE-------------------•-------------- •-------- •------------- <br /> BUILDING PERMIT ISSUED---------------------------------- ----------- •-------- <br /> --------------------------------- DATE <br /> -------- <br /> Alterations and/or recommendations:-.------- -----_ ----------•-------------------------------------•-- <br /> ------------------- <br /> �� " -------------------- - •----------• <br /> FINAL INSPECTION BY:----- / 1 -------- Date --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l30 South American Street 300 West Oak Street <br /> 132 Sycamore Street 814 North "C' Street <br /> Stockton, California <br /> Lodi, California Manteca, California Tracy, California <br /> ES-4-2M Revised W-2100 <br />