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-ZA <br /> ` APPLICATION FOR SANITATION PERMIT Permit No. _�'_ _ ----- <br /> (Complete in Duplicate) <br /> Date issued _ •- --��5-�-' <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 Orcli ce No. 549. <br /> JOB ADDRESS 4LO(?ATION--�CD Owner's Name-- --- . -•- - ----- ---------- --------P--h--o--n--e-_ <br /> Address----------------------- ------------------- <br /> Contractor's Name----------------------•---------- -•-•--•-------•---.------------------------------------------------------------------------------------ Phone--------•-- ------------------ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ r t <br /> Number of living units: ___/__ Number of bedrooms _ .. Number of baths ._1.... Lot size <br /> Water Supply: Public system Community system ❑ Private❑ Depth to Water Table -------- <br /> Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam f-1Clay E] Adobe�ardpan <br /> Previous Application Made: Yes E] No Sand/E] <br /> Construction: Yes [/No ❑ (A) <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public se,f is available within 200 feet.) C w1 <br /> Septic ank: Distance from nearest well, _' _Dista fro fpun ion____�_I!_.....-,Mater I ,..__.. <br /> p No. of compartments...___-------- --------- -i e. K_ Liquid'de th_----- �t--------�Capaci�ty-•_• -- .._ <br /> Dispos Field: Distance from nearest T-Q--Distance from foundation/-'-_/--/- _ _____:Distance to nearest lot li _ _... <br /> --- <br /> Number of lines_________ _ __ ___--------- Length of each line---------!'1__Q if...Width of trench_____ZA -___________-. <br /> Type of filter materi --- -_- epth of filter material-- ---Total length- �? ........................ <br /> Seepage Pit: Distance to nearest well__________ _________Distance from foundation--------------------Distance to nearest lot line-- _--__--._--- <br /> ❑ Number of pits-_------------------Lining material-----------------------Size: Diameter-___--- _-__--..:____.Depth--------------------------------- <br /> Cesspool: <br /> _________ ____-•-:---___-____Cesspool: Distance from nearest well.................Distance from foundation------_-------------Lining material------------------------------------- <br /> 0 <br /> -_ _-_--- _-- --.------ <br /> ❑ Size: Diameter--------------------------------------Depth - -.� ---------------------------------Liquid Capacity--_---------_-_--- <br /> Privy: <br /> ... --•- -----Privy: Distance from nearest well______________________ ___________-__-______Distance from nearest building----------------------------- <br /> El <br /> __----_--_---__--_ .-.-,-❑ Distance to nearest lot linne------ --- <br /> Remodeling and/or repairing -- <br /> describe : - -- ------------ •--• ----------------- <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)....... 5ia--- ------ ­------------------- ------------------------- --------------------------------------------- -----(Owner and/or Contractor) <br /> By:-------��1----- -- -- - - -•--------------•------------------------- -------- _---------------(Title)---------------- =- <br /> (Plot plan, showing size of lot, location o system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> CPO- <br /> APPLICATION ACCEPTED BY--- -------- ----------- -------- -------------------- ------------------------ DATE_ ------------------------------------------------ <br /> REVIEWED <br /> --- --- - -- <br /> REVIEWED BY- -------------------------- --- --------------------------- DATE_ �----------- <br /> BUILDING PERMIT ISSUED___.. -_-_. __ _____ DA E ----- <br /> Alterations and/or recommendations:_ l^ +� ._ "?- ___ , -_--- `-- ----- ' .(___-...' __._}�*^ �_/r:-4�_ <br /> - - --------------------------------- ---- - <br /> FINAL INSPECTION BY:---.------- d --_4_______________ _ ------ Date-------------- <br /> ------- __ i° <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 8-51 Revised W-2100 <br /> r - <br />