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APPLICATION FOR SANITATION PERMIT Permit No. .___-______•...-•_______ <br /> (Complete in Duplicate) <br /> Date Issued --------- -- ------ - <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. L �7_ 22-Z -`� <br /> J613 ADDRESS AND LOCATI -----kk_VJ44� ��.---- -------- + _tn� 'z-a -------------------------------------------•------------ <br /> Owner's Name------* ...... --------------------------------------•------------------------------------------------------------ -- Phone--•-••----•-------•----------•------ <br /> Address-----R-0'=----9-(.P------ -C>LA-----------------------------------------------------------------...... -----------------------------------------------------------•---- <br /> Contractor's Name----- =1-------- 'j-5------- 5` A---- - -° ----------------------------------------•-------------------- Phone----------------------------------- <br /> boa;f' <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ® CPHF'4<A <br /> Number of living units: ________ Number of bedrooms ________ Number of baths -------- Lot size ----------------_---------------- <br /> Wafer <br /> _____ ______Water Supply: Public system ❑ Community system ❑ Private K Depth to Water Table fid_ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑. Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe(b, Hardpan ❑ <br /> Previous Application Made: Yes ❑ No f&. New Construction: Yes K No ❑ FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) 1 1 <br /> Septic Tank: Distance from nearest well__,5D`_a-Distance from foundation-----I_o.._-_____. <br /> No. of cc 7-A <br /> depth------- ---------------Capacity-- Od--- <br /> Disposal Field: Distance from nearest well___SQ'_-t_Distance from foundation__ln3-_____.__Distance to nearest lot ......... CID <br /> Number of lines-_--------)------------------------Length of each line----------4i-_S?._________.Width of french----�4!.._____._________-___ P�) <br /> Type of filter material___rcn_c.L-------Depth of filter material-------k_7."-______.Total length-------5"C,_!_-------__________________ <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________________Distance from foundation--------------------Lining material--------------------__________.______. <br /> ❑ Size: Diameter------------------------- ------Depth----------------------------------------------------Liquid Capacity----------------------------ga <br /> Privy: Distance from nearest well _______________________________________________Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot line <br /> Remodeling and/or repairing {describe):--------------------------------------------------------------------------------------------------------------------- ---•----------------------- <br /> -----------------•----------------------------------- ------------------------------------------------------------------- --------------------------------------------------------...---•--•----------------------------- <br /> 9 <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, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) ....... ----------------------------------------- ---------------------------------------------(Owner and/or Contractor) <br /> ------------------------------------------------------------ <br /> BY: ------------------------------(Title}- <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---- --------------------------------------------------- --•----------- DATES 1 Q ' ----------------------------- <br /> REVIEWED BY------------------------------------ --------------------------------------------- ---------------------------------------- DATE--------- ---------------------- <br /> -------------------------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------=---------------------•----------------------------- DATE------------------------------------------------------------- <br /> Alterions and/or rec mmend atiogs-------------------------------------------------------------------------------------I-----------------------•--------------___---------------------------• .... <br /> 6-- <br /> ------------------------------------------------ ----------------------------------------------------------- . ---------- <br /> 2G Gf <br /> � ~ <br /> ---------_.._________________________.________-__________.._______-___.------------------------.-------------------.--------------------------------------------------------------------------------.--------------------------- <br /> --------------------- <br /> ---------------------------_----------------------_----------------________________________ <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 W Tracy, California <br /> LS-9-2M , Revised 1.57 F,P.CO. <br />