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APPLICATION FOR SANITATION PERMIT Per'mit'No.. _. ..-g_- <br /> n <br /> s <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. t <br /> This application is made in compliance with County Ordinance No. 549. , <br /> JOB ADDRESS AND CAT PN/......�- ------- ----�.;`-� <br /> Owner's , <br /> s. . <br /> Name "_------ �� ----------------------------------- i <br /> _ c -- --= --- -- - - 4'tg,�--�+�,�-: Phone-------- -----------7­ <br /> Address -------•---------------------------- --------- ----= ...._-. <br /> Contractor's me______________ <br /> sQ �� -------- - ------- •---- -- -- ---- Phone----._ /_ <br /> Installation will serve: Residence Apartment House 0 Commercial ❑ Trailer Court-F] Motel ❑ Other ❑ <br /> Number of living units: --./--- Number of bedrooms -c-- Number of baths Lot size _ eJ_ -�//d-------------=----- <br /> Water Supply: Public system Community system Private E] Depth to Water Tableft. <br /> A3 <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay,❑ Adobe Hardpan ❑ i <br /> Previous Application Made: Yes ❑ No�' New 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 /> S' ptic T nk: Distance from nearest well-----------------Distance from foundation_________--------Material----____-__---------__.__.--____---____----_--_-. <br /> C `�j No. of compartments--------------------------Size--------------------------------Liquid depth---------------- --°------Capacity----------------------- <br /> Disposal <br /> --------- ------ <br /> C Disposal i.e"ld: Distance from nearest well-_.............Distance from foundation----_----------------Distance to nearest lot line---_--_--___--_-- <br /> Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- <br /> Type <br /> --- ---------------------------Type of filter material-_-7---- ------------Depth of filter material-_-:-------------------Total length---____-__------__------__------___-_---.- <br /> Seepa e Pit: Distance to nearest well=s -__---Distance f m fdation--- p--------.Distance to nearest lot line-- <br /> in <br /> Number of pits----t""_______________Lining materia!_,/ +� ----Size: Diameter_--.-- -_ ar ' ,�' i <br /> �� De <br /> esspool. fi•om nearest well-----------------Distance from foundation-----.--------------Lining material------------------------------------- <br /> Distance❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-------------- -------------gals. r <br /> Privy: Distance From nearest well-----------------------------------------------,--Distance from nearest building-----------------_-----------------------. <br /> ❑ Distance to nearest lot line---------- ---------- ------------------- ---•--------------- <br /> Remodelin 5 and/or repairing ----- rrf <br /> ---------- -- -•---------------------------------------------------- <br /> -- --_---- <br /> - ------ •------ ---------•1___1 <br /> - ------------------ <br /> -----------------------------------------------------------------••-----------------------------------------------------------•--------------------------------------------------------------------------------------------- <br /> ------------------------------------- <br /> --------------------------------------------------------- ------- -------------------------------------------------------------------------•----------------------------•-------------------------------------------------------------------------------- <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, an rul and regulations of the San Joaquin Local Health District. <br /> -- ------------ --------------------- -_ _ _--Owner and o Contractor <br /> (Signed) - - g. { <br /> B <br /> -- - -- � --------------------------------------------------------------------------------------Title--- ..-�-� <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse sideL.11-11" <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- -------------------------------------------------------------------------------------------- DATE - <br /> REVIEWED BY------ ----•------- --- ---- -------------------- DATE_ .•sa" <br /> ------------------------------------------ <br /> BUILDING PERMIT ISSUED ---- --------------- ------------------------------------------------------------------- DATE-------- <br /> Alterations and/or recommendations:------------------------ li <br /> -----------•-------------------------------------------------------•-------------------------------•---------------- <br /> -------------- - ---------- -- F------------ <br /> 7 ----------------•--•-----------------------------------•----------------- --...-----... <br /> __ T <br /> j <br /> --------------------------------------------- ----------------- --------------- ---------------------------------------------------------------------------------------------•------------------------------••-------- <br /> FINAL INSPECTION BY--- ----------------------------- --------------------------- Date----- � - r � <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-9-2M Revised W-2100 <br /> 4 <br />