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APPLICATION FOR ,SANITATION PERMIT , Permit No. <br /> (Com plete�i n6uvllicate) <br /> Date Issued � 3f�" <br /> Application is hereby 'rnade 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. <br /> ro <br /> JOB ADDRESS AND LO ATION___ .__!� - <br /> .-------------------- <br /> Owner's Name_____ _ 1 <br /> Address-•------------ <br /> Contractor's Name -- ----• -- -- -- --------------------- ----------------- Phone__ <br /> ----------------- - ------------•--•--•------- <br /> Installatian will serve: Residence -Apartment House ❑ Commercial ❑ Trailer Court otel ❑ ther <br /> Number of living units: <br /> ' _I-_-_ Number of bedrooms _�._ Number o baths __�____ Lot size _�_ _____ ___ ______� � ����.�� <br /> Water Supply:. Public system ❑ Commiznify system ❑ Private Depth ta'Water Table ft. <br /> Character of soil Jo a depth of 3 feet:k'Sa'd Gravel 'Sandy Lo m - Clay'Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> i i f ; <br /> Previous Application Made: des ❑ No� New Construction: Yes No ❑ 1=HA;/VA«Y e�s No � <br /> TYPE;OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic:tank or`cesspool permitted if public sewer is available within 204 feet.] f <br /> ° _ t <br /> Septic ja,n k: Distance from nearesr well____ �Dist ce from foundation.:___ '___--Mater�jal______.__-•_--- --}._- :--__--•• <br /> a. No. of compartmAe$is + S¢*e ms Liquid deP� ---------- i aP ,tY = <br /> Dispos I, Fie d. Distance from nearest wel1�� : Distance,from-,-foundation +•Dista ' ^fnearestllof`lin _ <br /> Number of lines__`f__R " _. :Length of 6Qc lin> _ <br /> - tr --.Width of trench_ +.►,c <br /> ---------- <br /> Type of filter mafeTi * a ' 9 r 1 r <br /> Depth of filter matenal___-----I U___------Total en th:--------_"_�--J�--�s.-�-------------- <br /> Seepage Pit:, y y Distance fo nearest well_ _------------------Distance'from foundation_-..__.�__�_:-_.Distan e- to nearest lot line__ <br /> ❑ Number of pits------ ----- ------'Lining material----------------t------Size:-Diamet;r---=•-----:--.- ---..Depth---------.----------------------- <br /> �. <br /> r r <br /> Cesspool: Distance from nearest well-----------------Distance from'foundation----- __ --Lining material__ _____ ____ ______"___-___._. <br /> ❑ Size: Diameter-------- i --._._'_Depth----- ----= ---- -- ------- -Liquid CapacifY gals. <br /> �. *. # - , <br /> Privy: Distance from nearest well_____________________._-___-___._.____-__.._----Distance from nearest j uilding__--- __.___ __.____-.____-__..____. <br /> ❑ Distance to nearest-lot•line__-^~~_------- - � ,.� �- ------------- <br /> T ,. ----------- <br /> Remodeling <br /> ----- -- . <br /> Remodeling ayd/orrepairi 9 (des n ej. __. = f ,---- <br /> -- ------------------------- --------------------------,--- .------ ------------------------------ -_-- -------- ------------, ;---------- <br /> I hereby certif t l have prepared-this-applicafion and that the work will .be done-in accordance with San Joaquin County <br /> ordinances, St s,oO rules a r gulations of the San Joaquin Local Health District. <br /> f <br /> f [Signed ------ ----------i--------------------------.---------- - ----(Owner and/or Contractor]` <br /> ------------------------- <br /> ------------------------------------------ (Title)---' <br /> Y� <br /> - - <br /> (Plot plan. showing size of lot, location of system in.relation to wells,, buildings, etc., can be placed an reverse side): <br /> y <br /> FOR DEPARTMENT.USE ONLY ' <br /> APPLICATION ACCEPTED BY __- ____-- -_ <br /> } <br /> = DATE S----- ----------------------•-------- <br /> REVIEWED BY ------ - DATE---- --=----------------- <br /> ,. <br /> BUILDING PERMIT ISSUED-----------------•---------------------------------i— - 4 DATE s <br /> t ---------------------- <br /> Alterations and/or.recommendations- <br /> - ------- ------ --------------------------------------------------------------------------------•-- ---­-------------------------------- <br /> -------------------- <br /> ji <br /> -------------------------------- -- -------------------------------------------------------- --------=--------- -------------------------•----•---------• ----....._._--•----- <br /> 4 <br /> --------------- <br /> :/ <br /> FINAL INSPECTION BY: = =! -- ''�'1 Date-_ _ -_ 2 _`7� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Streot 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 1.57 F.P.CO. <br /> 1 .i <br />