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14 L <br /> 11-17 APPLICATION FOR SANITATION PERMIT Permit No. ..._.�_�.............. <br /> (Complete in Duplicate) Date Issued ----------------- <br /> ssued --- <br /> l r� -3 <br /> •-- -----•-•------ <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. 549. 5 a—f/O--09 <br /> JOB ADDRESS AND LOCATION_ _ __ ----- ---- �, f g <br /> Owner '' <br /> Owner's Name------------- 1"' '1al� fj{/ --------------------•------------------------------------------------------------ - <br /> Phone.`- --------- ---- ----�--- <br /> Address-•-.----------'Ire---- ..... ------------- ----------------------------------------------------------------------------•-•-------- <br /> Contractor's Name--------------------------- -• ------------------------------------------------------------------• ------------------------- Phone--------------------------- ------- <br /> Installation will serve: Residence ❑ Apart ent House ❑ Commercial ❑ Trailer Court ❑ tylotel be Other ❑ <br /> Number of living units: __ _ Number of bedrooms __-ii___ Number of baths ----?� Lot size ------ ._'_',-_.________________________"_.__________.__ <br /> Wafer Supply: Public system ❑ Community system ❑ Private,4 Depth to Water TableP ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loom I] Clay�l)ffr Adobe ❑' Hardpan ❑ <br /> Previous Application Made: Yes No E] New Construction: Yes, No '7 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> of errriitted if public sewer is available w! in 200 feet. <br /> (No septic tank or cesspool p p 01/ <br /> Septic Ta <br /> nk: Distance from nearest well------ from fol"11-dation__._____ <br /> No. of compartments--------------C __.__Size- --Liquid`depth _ Capacity_- CapacitY_ iLE7rr-fy�'1__. <br /> Disposal Field: Distance from nearest well__1_a +�_Distance from foundation.____�1- _....Distance to nearest lot line____---l-. <br /> Number 0.1 lines-------------.j------------_"-.__ ength of each line_______/4­0____.___.Width of trench.._._ "-_ // I °C <br /> r� <br /> Type of filter material___„ ' *40eepth of filter maireriaL____� _ Total length "__�_e _f _________._ "z <br /> �kage __.Distance to nearest lot line___________ <br /> it: Distance to nearest well______________________Distance from foundation____-____________ <br /> Number of pits----------------------Lining material-----------------------Size: Diameter----------------------Depth--------------------------------- <br /> �•l <br /> Cesspool- Distance from nearest well-------------____Distance from foundation-------------------.Lining material-------.----------------------------- <br /> 1 � ; <br /> Size: Diameter------------------==-- -- --------=-Depth--------------------------------_- ---------------Liquid,Capacity -------------------------ga s:, ; <br /> Privy: Distance from nearest well---------------------------.---------------------Distance from nearest building------------------------------------------ <br /> EI Distance to nearest lot line.-------" --------------- --- ---- �[ <br /> ------------------- <br /> Remodeling and/or repairing (describe):.-- �^ *mr �� d' <br /> ---------------------------- --------------------------------------------------------------------------------- -- -------------•------------------------ <br /> - ----------------- ------------------------------------------•----- --•---------------------------------------------------------------------------------------------------------------- ---- <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and reguI ti, s of the S •''Joaquin Local Health District. <br /> /. <br /> (Signed} --------- -'-'°` ` � ------------ -------------------------------------------------(Owner and/or Contractor) <br /> By:-----------------------------------------------------------------------------------------------------------------------------------tTitle)------------------------------------------- -------------------- <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 /> APPLICATIONACCEPTED BY - --- --- ------ -- ---------------------------------------- DATE------------------------- ---------------------------------- <br /> REVIEWEDBY--------------------- ------------------------ - DATE------- ./::m <br /> BUILDING PERMIT ISSUED DATE------ <br /> - --- - --- - ------------------------------------------- <br /> Alterations and/or recommendafjqpns- - -y------- ---- - - -- <br /> . �®�1 ''sr - - ----- - ------- - <br /> -- - --------- - - - ------- <br /> I �-_ -t---------------- <br /> dC <br /> FINAL INSPECTION BY--------------- ------------ 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-4-•-2M 10-52 Revised W-2100 <br />