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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (complete in Duplicate) 3. >Y- <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. <br /> This application is made in compliance with County Ordinance No. 549. <br /> p� 1 <br /> JOB ADDRESS AND LOCATION....N�..- _... 1��.I._. ! t------------------- <br /> A <br /> --_ <br /> �a <br /> Owner's Name------ � `- `� v ---- C ------------------g------ ---_-_ Phone----.. 1 ��...... <br /> Address ---- ----- <br /> Contractor's Name------.. P I i--------------= ------------• Phone. <br /> - ------ <br /> _--_ . . �_ <br /> Installation will serve; Residence �partment House ❑ Commercial 0Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ..._. Number of bedrooms __=___ Number of bags --__�_. Lot'size x..�.z' -------------------- <br /> Water <br /> ---•.-.- --- <br /> ,� -- <br /> Water Supplys Public system ❑ Community system ' Private ❑ Depth;to Water Table i? ft. <br /> Character of soil to a depth of 3 feet: ;Sand Gravel 171Sandy Loam Clay Loarr>_❑ Clay ❑�t Adobe Hardpan <br /> Previous Application Made: Yes ❑ No New Construction: Yes IIJo ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: M1 <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) nn <br /> Septic,Tank: Distance from nearest well_�O Distance from foun ajan .,_O .__.Mate al 'e e <br /> cam. <br /> No. of compartments..___.. '"-.____.S¢e_ .�.-�--d---_ _Liquid dep}h---------------..-.-____-_Capacity....Dispose Field: Distance from nearest ell___ Distance from fourfition '� Distance to nearest lot Ime���7 <br /> Number of lines_. _.____ Length of each line........ �!. Width of trench.._... .�.. __.... <br /> Type of filter material_ �r::!Z__'-Depth of filter material-----A------------ length........ -................ <br /> Seepag it: Distance to nearest°well ,--- ____Distance from foundation.... ._.O.._..Distarlce to nearest lot ne4Z d.._.. <br /> Ey Number of pits-------�_______ _Lini Diameter____,..............Depth----le._ <br /> P e irriaI__,,V_A_9n,_eSize: <br /> Nli– r <br /> Cesspool: Distance from nearest we _________________ tance from foundation---.----------)____:Lining material---------,............................ <br /> Size Diameter_-. Depth Ligwd Capacity. S <br /> u.. " <br />:. ... <br /> Privy. Distance from nearest well n _" - ----- Dis `nee"frotr - <br /> ❑ Distance to nearest 4**, ------------------•-----------•--•------------------------------------ --- ------------------- <br /> Remodeling and/or repairing (describe)--------- ---------------•--....-----•--•--•-•-------••-------------•--•••......••---••---------•---- -••-•--- ------•• --------•••..... <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, la , and rules and ragu ns tioof the San Joaquin Local Heam'District. <br /> (Signed) Sta -- ••-------- ------------------------- -----------------------------------------(Owner and/or Contractor) <br /> By:............................................ -----------------------------------------------------.... --_--•---------- (Title)-....................................I•....... ------ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------------- ------ -------------------............................................ DATE........ . •-- - <br /> REVIEWED BY DATE <br /> ---- ---------------------- <br /> BUILDING.PERN114TfSSUW..... = --------- -------- -- ------- ...:.: .,... � . 1 ......- ............-- <br /> Alterations"and/or recommendations:............................................................................. ----.._ ..,..I. .................................................. <br /> ...--••............... -•---- ...--- .. ------ ......... --- <br /> FINAL INSPECTION BY:...®---- ............................._­---�••---• Date------- - -----•. <br /> SAN JOAQUIN LOCAL HEAL 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 />