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�s 1 (�'J APPLICATION FOR SANITATION PERMIT Permit No. _.. _._..... <br /> (Complete in Duplicate) Date Issued <br /> Applica4ion 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. S49. ' <br /> .�' `- <br /> JOB ADDRESS AND LOCATION--- __- 7--=-- ! ------------------------------- <br /> Owner's Name <br /> -C--�-- -��� -------------- ---;--------------------------- ------ Phone----------------- <br /> --------------------------- <br /> Address------ -/ .3----•-•• - ----- ------------------------------------- •----------------•------------------ <br /> --------------------------------- <br /> Phon ------ - ------ --'- <br /> ---- <br /> eContractor s Name-----. -- •------------------- <br /> Installation will serve: Residence partment House ❑ Commercial ❑ ' Trailer Court ❑ , Motel ❑ 'Otherr ❑ <br /> Number of living units: __f____ Number of bedrooms __ __. Number of baths -__)� Lot size ___Sno..____.A_4..o_a--------------------- <br /> 7 - <br /> Wafer Supply: Public.system mmunify'system ❑, Private E] Depth to Water Table .9s1 ff' —4, <br /> Character of soil to a depth of 3 feet: Sand E] Gravel F1 Sandy Loam Clay Loam ❑'Clay E] _Adobe ardpan ❑ <br /> Previous Application Made: Yesr❑ No A7—New Construction: Yes ❑ No "" r <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: , <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> ---------- <br /> Septic <br /> Septic Tank: Distance from-nearest well�t Distance from foundation__-__ Material__ <br /> ------_-._:Size--- --- - - ._Liquid depth-_--% Capacity--• l� <br /> �..... No. of.compartments_-.___.-- ,0 <br /> Disposal Field: Distance from nearest well--"---.-----------Distance from fc6dation-------------------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---------------.---------------•---------- <br /> Seepage Pit: Distance to nearest well----------------------- from foundation.../ ......-.Dista�n+ce to nearest lot line--- <br /> Number of its. Linin material. ___.Size: Diameter-_ _ __________Deptn__.�.■f__-- -___ _________ <br /> p g <br /> f 1 ' <br /> Cesspool: Distance from nearest well------------------Distance from foundation-------------------- Lining material------------------------------------- <br /> il, <br /> ❑ Size: Diameter- ------- -- --- -----------------Death--------------------------------------------------_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 /> 1 <br /> ar +� 4 -------------------- <br /> �N.- ---%---------------- <br /> -- ------f--------- --------------- -------`•--------•-'- ••-'-r`•f�•_—_ - '-��.'__-__--_.'.._-------------------•--•{------- --------------------------------------- <br /> IF � <br /> ______ ------------------------------- J V <br /> I hereby certify that I have prepared this-applicafion and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the S n Joaquin Local Health District. - I <br /> (QwFa*.�er+Contracfor) <br /> [Signed) <br /> •---- ---- <br /> B ' °"'" ------------------------------------------------- <br /> (Plot <br /> - ----- --_(Title)--- ------------------- <br /> y, F <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can 'be placed on reverse side). <br /> e <br /> ° FOR DEPARTMENT USE ONLY <br /> DATE------------•-• J <br /> APPLICATIONACCEPTED BY------------------ ---------- ------- - =------------- �--------------------------- - �-�--�'�---------------------- <br /> REVIEWEDBY-------------------------------------------- --- ----------------------------------- DATE--------------------•-------------------------------------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------- -------------------------------------------------=- DATE------------------------------------=------------------------ <br /> Alterationsand/or recommendations:------------------------- -------------------------•------------•--•-----------------------------•---------............-------------------------------------- <br /> ------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------! <br /> ---- ----- --- <br /> i <br /> ---------------------------------------•--------------------------------------------------------------------------------------------------------'-----------•-------1-------------.----•------------------- <br /> ----------------^-f-- - --------------------- _ <br /> ---- <br /> �a D <br /> 1J ------------- <br /> ---------------------- <br /> FINAL INSPECTION BY:------------=--I[_-=------- - - a 7. ... <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 Revised W2i00 <br />