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APPLICATION N I=OR SANITATION PERMIT Permit No. ---�_ __... <br /> [Complete in Duplicate) �� <br /> Date Issued _� <br /> y <br /> Applica'ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descr' d. <br /> This application is made in compliance with County Ordinance No. 549. <br /> gin► ; <br /> JOB ADDRESS AND OCATION_�!- �_ <br /> -- - - --------- <br /> ------------- <br /> e — -r <br /> Owner s Name----- -----_/!2�:-----�-------•----- -----------P---- ------------vl Phone---�-�1---�--��--a�.----- <br /> ----------- ---------- <br /> Address d_:_ - <br /> -9_ - -- - --------- �-a <br /> -- <br /> ------------------------------------------------ -- <br /> Contractor's Name------ ----- ----- ------- =-------- Phone -••-7 <br /> ------------ ---------- -- <br /> ------- - -•--------.._. <br /> Installation will serve: Residence Ej -Apartment House [] CommercialT T ailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: --"' Number of bedrooms - Number of�s <br /> Water Supply: Public4•system'2___C_ommunity system ❑ Private ❑ Depth to Water Table .- -- ft; <br /> Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay oam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Constru tie : Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is availab a wit in 200 feet.) <br /> r' <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material <br /> ---._-------_----_._-_ <br /> ❑ Noof compartments-------------- ---------- Size--------------------------------Liquid depth--------------------------Capacity---------------- r _ <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line--------- V l <br /> ❑ Nu`mber, of-lines_-..---`-----------------------------Length of each line------------------------------Width of trench <br /> Type of filter material------------------------ Depth of filter material--------.-------:------Total length-------------------------------- <br /> See a e Pit: ' Distance to nearest well--`_+_ p'i`stance fro foun ation---... _----_ �.7 Distance to nearest Igg,t line -:-�d------ <br /> Number of pits-_------/---_.___.'--Lining material-C_ Size: Diameter-_.3 QC J <br /> Depth----CO-1,16- <br /> Distance'from nearest well-----------------Distance from foundation------------------- Lining material-------------------------------------- <br /> Size: <br /> -_--..------_:--____---.--_ <br /> Sizer Diameter-------=------------------------------Depth--------------------- Liquid Capacity gals. <br /> Privy: Distance from nearest well----------------------------- ----------------Distance from nearest building-_------_----.--___-----__--_ <br /> ❑ .. Distance to nearest lot line-----------------------------------------------•-------•-- = <br /> -------- <br /> Remodeling and/or repairing (describe)---------------------------------------- � h <br /> ---•------`--------------­----------- <br /> -------------------------••----------- ------------••--------------------__• •------------------- <br /> ------------------------ ------------------------------------------------------------------•-- ----------•----------•-----------•-------------- <br /> 1,hereby certify that-l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State s, and rules and regulatio of the San Joaquin Local Health District. <br /> [Signed) --- - ----- ------- --- - ---------- - ------- --- -------------------<--------- - o <br /> --- �and/o�rContractor) <br /> By---------------- - --------------- - ---- ---------------------------------------•-----------------------•----(Title)--- <br /> (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> ' f FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION KATION ACCEPTED BY - ----------- DATE_------- <br /> REVIEWED BY - -------------------------•------------------ DATE- <br /> BUILDING PERMIT ISSUED <br /> 1 <br /> --------- <br /> ----------------------------------------- -------------- DATE.--------------------- <br /> -------------------------------------- <br /> Alterations and/or recommendations=----------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------- --------------------------------------------- <br /> ---- <br /> ------------------- -----------------•R-----------------..---------.:..------------------------------------------ ----------_---- <br /> ----------- <br /> ..._ <br /> ---------------------•---•-----•-•----------••-------•----------- <br /> ------------------------------------- <br /> --•--------------------- ---------- - -------------------- ------- -------------------------- ------------------------ ---- <br /> FINAL-INSPECTION-BY:------- -11-:- %` !-�"!f'_ = - Date 1 = 5 <br /> ------------------------------------------- <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 />