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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) f l <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 Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION.../,-Or--/...............,�_-�_�_.�--� ............. _.-........ ----44_ i „ <br /> Owner's Name---. ( Q �� �.----- r--------- -----------1­-------I---- ----•-------- -------- Phone------------------------------------ <br /> Address-- --•---,-10, +[Gr7-.,..----�r--6-1- rll&..t.. �� A................... --------------------------------------------- <br /> Contractor's Name----... _ - --------------------------- --_------ Phone...........................------ <br /> Installation will serve: Residence 04 Apartment House ❑ Commercial 0- -Trailer Court.❑ Motel ❑ Other''❑_. <br /> Number of living units: -------- Number of bedrooms _I_ Number of baths -1.... Lot size ___ ! . _ _-------------­---------- <br /> Water <br /> .-__ ___- _---_-__ <br /> Water Supply: Public system ❑ Community system ❑ Private JM Depth to Water Table%___ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel n Sandy Loam J4 Clay Loam ❑ Clay ❑ Adobe❑ -Hardpan <br /> Previous Application Made: Yes ❑ No New Construction: Yes ;V No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sew is available within 200 feet.)�"+/" /j <br /> Septic Tank: Distance from nearest well__,�.Q"_ _Distance fro fo yi�' �_ Material! �.'�' �" <br /> No. of compartments-------2--------------Size ,K_3_ - !liquid depth---- ,�`_---_--_Capacity_? {-- <br /> Disposal Field: Distance from nearest well 741-�ristance from foundation l '�.._ Distance to nearest lot line---i,�� <br /> (� Number of lines_____. _ i Length of each linelitat__� L_ . idth of french--- <br /> 7, ,�,, --------- <br /> Type of filter material t9_Gi- Depth of filter material-/ --- e__--_Total length-__ _.9_�_.- _________________ <br /> Seepage Pit: Distance to nearest we I----------------------Distance from foundation....................Distance to nearest lot line----_------------ <br /> 171 <br /> --_-___.-_❑ Number of pits----------------------Lining material-----------------------Size: Diameter........................Depth..............----------- -•---- <br /> Cesspool: Distance from nearest well................. from foundation-_-- ---. .Lining material....................................... <br /> ❑ Size: Diameter------------------------------------_Depth------------------ -------- -•--------------Liquid Capacity. gals. <br /> .._... ---- .. <br /> Privy: Distance {rorn nearest well __-----------------------------------------Distance from nearest buildfng-- ------------------------------ <br /> [] Distance to nearest lot line ----- ----------- •---•-------- --- --- -- --------- • ------- ---------- <br /> Remodeling <br /> --- --_Remodeling and/or repairing.(describe)------- -------------- ----------------------------------------- ............................................................----------------------• <br /> -- ----•---- ------- --------------------------------------------•---------------------------•---------•----•--------------------------------------- -------------------------------- <br /> ------------------------------------------------ <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 /> (Signed)..- r x s r'd (Owner and/or Contractor) <br /> By� --•-•-----------------------------------------------------------•-----------------------••--------------------•----------------(Title)--- ^l'- ^' --------- -- ------------- <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 ......... --i--_ TE--- _�/�' ,� ---------__ <br /> REVIEWEDBY------------------------- - ----- -- --------------------- ------------------ ------- --- -- -------------- DATE------------------------------------------------------ <br /> BUILDING <br /> ----------- -------- --------------- ----------- <br /> BUILDING PERMIT ISSUED-----------------------------------------------------------------------------------------------------• DATE------------------------------------------------------------. <br /> Alterations and/or recommendations:. -- -------------- <br /> -------------------------------------------------•----•---------------•------.............................--•-..........................•-................................................................................. <br /> ------ --------- ------------------------------------------------------------------- ----------r------------------------- <br /> WFINAL 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 10.52 Revised W-2100 <br />