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7 APPLICATION FOR SANITATION PERMIT Permit No. . __GaS: <br /> ti (Complete in Duplicate) <br /> Date Issued ____ <br /> Application 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 Ordin nce No. 549. <br /> JOB ADDRESS AND LOC T N U 4_ - - ------------------------------------•---------------------------------- ------------ <br /> -- --------------------- - ---- ---------------------- <br /> Owner's Name .. Q �� -- ----- ----- f I-------- --------------------------------------------•--•"----------------------Phone..;._ _.:'.-- ------------- <br /> 141Z 0 <br /> ` -7 <br /> Contractor's Name-------------- /--------------- ----- 1----------------------------------------------------------------------- Phon _ -------�r��-7 < <br /> Installation will serve: Residence �rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> i <br /> Number of living units: ___�"- Number of bedrooms _,m Number of baths ___/__ Lot size "ra _- _ _10gA_1---------------------------- i <br /> Water Supply: Public system 2--tommunity system ❑ Private ❑ Depth to Water Table&d ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E]--Tqardpan ❑ <br /> Previous Application Made: Yes ❑ No [-�New Construction: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: [may <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) `31` <br /> 4 <br /> SepticT n� Distance'from nearest well-----------------Distance from foundation--------------------Ma#erial------------------------------------------------ <br /> ❑ • �,.. �--.1 <br /> No. of compartments-------------------------Size--•-----------------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well--------_--------Distance from foundation--------------------Distance to nearest lot line--- .-"_...._ <br /> ❑ Number a1 lines-------------- --------------------Length of each line------------------------------Width of trench-------------------------_---____-- <br /> Type of filter material-------- _____________Depth of filter material----------.-----------Total length------------------------------------------ <br /> Seepage,Pit: <br /> _____________________-__--__-----_--___.- <br /> See a e,Pit: Distance to nearest well------- ---------Distanc 8(o� fou afion___�d...___.Distance to nearest lot line-- ._____Number of pits_____:._____________Lining material_� _ r Size: Diameter---f�_ f-----_-_----Depth__:� ..________--_--_-_-._-_ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------Lining material__-___._.._.___.____-______.___.____ <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------- --------------.-Liquid Capacity-.--------------------------gals. <br /> Priv Distance from nearest well-----------------------------------------------___Distance from nearest building______, ---------------- <br /> ❑ Distance to nearest lot line-------------------- -------------------------- ------------------------------------------------------------------------------------------- <br /> r� ' <br /> t <br /> / <br /> = � <br /> Remode�ng an /or repairing (describe):------------------------------------------ � <br /> ' <br /> r ------ <br /> a <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 lav s, and rules and regulations of the San Joaquin Local Health District. <br /> Si ned ----- <br /> - tmer,and/or Contractor) <br /> ( 9 )------ <br /> �Y�------------ <br /> --------- - r- --- ------- (Ti+le) <br /> ---------------- <br /> (Signed) <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 /> APPLICATION ACCEPTED' BY------------------------- - -- ------- -- ----- DATE <br /> REVIEWEDBY----------------------------- ---------. DATE ------- L--- ---------- ------ <br /> BUILDING PERMIT ISSUED--------------------------------- _ <br /> Alterationsand/or recommendations:------------------------------ -=----------------------------••------------------•----------­-­----------...............................1--••-••---------- <br /> ------------------------ <br /> , <br /> -----•----."-"------- ----•-----------•----------------•---------------- - - <br /> ----- --• - ------------------------------------------------------------"-------------------------------------------------------- <br /> i�-------------------------------------------- -•-----------------------------------------------------------------------"----------------------------------------------------------------------------------------------- <br /> 4 <br /> -------------------------------------------- --------------------------------------- ----------------------------------------------------------------------------------------------------•----------------------------------- <br /> Date-. I ' <br /> FINAL INSPECTION BY--._____,�'1 _ <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 10-52 Revised W-2100 <br />