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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> . Date Issued <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 AND LOCATION------ <br /> rc ' ?I " <br /> Owner's Name--- '1 t f--- 7?l (t r *•S/----•---•--------------------- ------ ------------- ----------------------- Phone_}' -s _0 f�S� <br /> Address__..--•�v `� X ----------j �_C_ '� <br /> Contractor's Name-------------��..r�YI_' --------------------------•-----------------•------------------------------------•------------------- Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---/-. Number of bedrooms ,Z__ Number of baths ___1___ Lot size -------------------------------- <br /> Wafer Supply: Public system U-<ommunity system ❑ Private ❑ Depth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe a' ❑ <br /> Previous Application Made: Yes ❑ 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.) V <br /> Septic Tank: Distance from nearest well77a_40449IDistance from foundation---/__41__f.....Material_�L' + -��'a - <br /> No. of compartments --------------- -Liquid depth_ Y. .-____---_____-_Capacity_- ��- <br /> e <br /> Disposal Field: Distance from nearest well--y?oWDisfance from foundation---/_Q "___.Distance to nearest lot line_---______ <br /> ®-- Number of lInes-----r---------------------------Length of each ---(----------Width of trench---.ice((_`_.----_.-__--------.. <br /> Type of filter material2i1_iZ.0-k-----Depth of filter material/9`r--___--Total length-----/-- `______________________ <br /> Seepage Pit: Distance fo 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----------------------------gals. <br /> Privy: Distance from nearest well _________--------------------------------------Distance from nearest building------------------------------------------ <br /> El <br /> __-_--______________-.`_____________.__.❑ Distance to nearest lot line------------------------------------- ------------------------------------------------------------------------------------------------------- J <br /> Remodeling and/or repairing (describe)-------------------- ------------------- -------------•---------------------•-•-----------•-------••-------------•-----------•-------------------------- <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, and rules and regulations of the San Joaquin Local Health District. <br /> - r-----------------------------------------------------------------------------------------------(Owner and/Am,Contractor) <br /> B • <br /> Y•------------------------------------•------------------------------------------------- --- ------------------------------••---•--..(Title)------- - ------ ----------------.. <br /> --------------------------- <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----- <br /> BUILDINGPERMIT ISSUED.----•---------------------------------------------------------------------------------------------- DATE------ " -- ----------------------------------------- <br /> Alterations and/or recommendations---------------------------------------------------------- ------------------------------------------••------------------------------- <br /> ------------------------------------------------------I.,-------------------------------------------------------------­------­­----------- ----------------------------------------------------------•------------------- <br /> FINAL INSPECTION BY:. ------ - ------- --------------------------- Date---------{---" . <br /> AN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M : Revised W-2160 <br />