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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date issued ._5 )S7- <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 application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS ANB.LOCA ION____ '` <br /> --)--I_-1------- -------------- <br /> Owner's Name ---- ---- .•� ` '�� `= Phone------------------------------------ <br /> Address <br /> - <br /> Address---------------------- =_ ---------------- <br /> Contractor's Name.- --- ----- ----------------.__ Phone--------••------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial .'❑ Trailer Court ❑ Motel E] Other ❑ <br /> Number of living units: __ Number of bedrooms umber of baths ---f__-Lot size _-__-?4?---7__A---7__ __------------------- <br /> Water Supply: Public system Community system Private ❑ Depth to Water Table -__-_.-. ft. ! <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe E] Hardpan E]Previous Application Made: Yes E] No �ew Construction: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation---- ____--------.Material-__----_---_._-------------_-----___.__..______. <br /> ❑ No. of compartments------------------ -- Size--------------------------------Liquid depfh--------------------------Capacity------------------- <br /> osa -- <br /> Dispield: Distance from nearest well__----Irb, _Distance from foundation to nearest lot line_----5---____ <br /> Number of lines------------------- Length of each line--------------bd.r.....Width of french-------------!?�4-/1-.----____. 1 <br /> Type of filter material---------- Depth of filter material--------- '7-----Total length------------6-Q------,__-------•:f_ <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 /> `,O_ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- I <br /> 171Size: Diameter--------------------------------------Depth--------------- ------- ----------------------Liquid Capacity- --------------------f--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 /> ---------------------•---------------------- <br /> -------------------------------- - ------ ---- - <br /> v4 ?� ` <br /> --------------------------------------------- --------------------------------••------------------------- ----------- -- ---------- <br /> �----------------------------------------- <br /> ------------•----------------------- <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, an rules nd regulations of,fhe San Joaquin Local Health District. <br /> /JB l <br /> �yy�� r /! <br /> (Signed) _.'..`..... -- -- ----------------------- (Owner and/or Contractor) <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 /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------------------------------------- --- -------------------- - <br /> - -- --- --- -- - ------------ DATE----- --- •---- - � - <br /> U` g - <br /> REVIEWED BY ---------- ---- ------------------------------­­ DATE------------ <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------••--------------------------------------. <br /> Alterations and/or recommendations:_---_------. <br /> ---------------------------------------------•---------•-----------------------------•--- <br /> -• ---------------------------------------•--•---•---•-------------------------_.------------------•-•---•-----------.-.....---------- <br /> ---------- --•---------------------------------------------------- -------------------------------- ------•---------- -----------------------------------••-------•-------------------------------------------------- <br /> - -------------------- -------- --- -•--------- -------- --------------- ---------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:-----------------------------0ry---- .:---�------- Date-----------------&`-------q------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ; Revised W-21!00 <br />