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APPLICATION FOR SANITATION PERMIT Permit <br /> }_ ` (Complete in Duplicate) <br /> - Date Issued _____ _���•�� <br /> Applica+ion is hereby made to the San Joaquin Local Healfh 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 /> 1 /% <br /> JOBADDRES2ALO�CATI�N------ - ----�(----------� ---------------------------------------•-----------=--- ----------------------------------------------------------------Owner's Nam ----- ----- ----------.. Phone-------------------------- <br /> Address __ <br /> ' Y <br /> ------------------------------------------------- - <br /> Contractor's Name___________ _ <br /> - _ .. Phone..(/-- _ <br /> Installation will serve: Residence 0 ,Apartment House Commercial 0 Trailer Court ❑ Motel ❑ Other ❑ 1i <br /> Number of living units: ---4. of bedrooms ---r7 Number of baths _/__ Lot size _-__S_a_X_/__c�__�___ <br /> Water Supply: Public system ❑ Community system ❑ Private _ Depth to Water Table -41--o- ft:" <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ <br /> Previous Application Made: Yes ❑ tNo New Construction: Yes No E]TYPE OF INSTALLATION AND SPECIFICATIONS:` "' '_� <br /> (No septic tankor cesspool permitted if public sewer is available within 200 feet.) <br /> - - , , v.rM . + <br /> Septic Tank: Distance from nearest well---��0______Distancq,from foundation_____�4_______.Mater::_�____�___________ <br /> No. of compartments----------'---•-----------Size_,�L_1_CiG,K_r-'------Liquid depth------�j_�_--.�.--------:Capacity----- ----401--- , <br /> Disposal Field: Distance from nearest well---.- <br /> _,__Distance from foundation--___e2__°_______.Distance to nearest lot line___J-____________� <br /> Number of lines_E._____3 ---��__ __Depth'of`filter materiaL__,ft' '!____;,____Total length_'_/ _1a�__ _____________________ <br /> -0. i. <br /> Seepage Pit: Distance to nearest'weld----------------------D.istance from foundation___________________Distance to nearest lot line_______.________ <br /> ❑ Number of pits--------------------- Lining material-----------,<-$ Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest wel_`______________Distance from foundation--------------------Lining material__.__________________________--___-_. <br /> Size: Diameter------------------------- --------.Depth------------__------Ns--;_----.- -.---------.'_----Liquid 'Capacity gals. <br /> Privy: Distance from nearesf well------ ----------------------- :______Distance from nearest building_________-______________---___--_--_----. <br /> ❑ Distance to nearest lot line--------:--=------------------' '"'.r ----------------- = -------------------------------------- _ ---------- <br /> �r <br /> Remodeling and/or repairing,(describe)------------------------------------------------------- <br /> ---------------- - •-------• ---••--•-------------------- <br /> ------------------- <br /> -----------­---­----• •--------------••------------------------------------------------------------------------;; - --------------------------,-------------------------­-------------------------I------- <br /> - ;�' <br /> --..------------------------------------- <br /> ------------ <br /> --------- <br /> .--------- <br /> Y ---- ----- 1= <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) ------_ ----------- ------------------------------ ----------------------------------------- __O er and or Contractor$ i . ..Qc --------------------- --------------------------- Title <br /> Y:------------ [ -- - <br /> (Plot plan, showing size of lot, location system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY----- - --------------- DATE---------------------------- ........—------------ <br /> ---REVIEWED BY-------------------------------- <br /> BUILDING PERMIT ISSUED- ---- ----------------------------------------------------------'----------------------- DATE---------------------------------------•-- ------------------ <br /> Alterations and/or recommendations---------------------------------------------- ---------------I------------------------------•--------- = <br /> --------•------------•-------------------------------------------------------------------------------------------------------------------------------------------------•--------`-------------•--•---------------------- <br /> ----------------------------------------------------------------------------------------------------------=-------------------------------'----------------------------------I--------•---------=------------------- <br /> -----•----•------------------------•--------------------------------------------------------------------------------------------------------•---------- -------------'------------------------------------------------------ <br /> ------•------------------------ ----------------------------- ----------------------------------------------•----------------------------------- <br /> � 7�J�iG r Z f X3'3 <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 Tracy, California <br /> ES-9-2M Revised W-2100 <br />