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APPLICATION FOR SANITATION PERMIT Permit o. ..lP_� <br /> (Complete in Duplicate). � <br /> •r 1 ,•, � � Date Issued <br /> Applica-%n is hereby made to the San Joaquin Local Health District for a perm' construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AN OCATION_ I- t! .et ------------------------------`-----------•------------------------------------. ------ <br /> Owner's Name.-- . •• ---------h--•00 --am -- <br /> - •--------------------------- Phone.................................... <br /> Address------------ac, ---- - . � <br /> ----------------------------------------------------------------------------------------------------------•--•----.....------......----••-••----•--•--- <br /> Contractor's Name= `- - t-tel.. t --------------------------------------- Phon�..�t.-s.e!.'-_' L�•-4----- <br /> Installation will serve: Residence ,._Apartment House ❑ Commercial ❑ Trailer Court ❑ tel Other ❑ <br /> Number of living units: --1--- Number of bedrooms .,'j,.r- Number of baths ------ Lot size ------------ <br /> Water Supply: Public system ❑ Community system ❑ Private §—Depth to Water Table +(rft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe dardpan ❑ <br /> Previous Application Made: Yes ❑ No A-- New Construction: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material.________-_____________----------_______.___:•--. <br /> ajQNy . No. of compartments---------- -------- Size....................--..........Liquid depth--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well__S'o_ _"__.:.Distance from foundation-___ ..._.Distance to nearest lot line--4 ...... <br /> [IL, Number of lines--------,-___.__ _ Length of each line______ZA.'___.�.____.Width of trench.-_ I.N.'"_________________ <br /> Type of filter material -471N___Depth of filter material_____U.r� ________Total length....to-_-_ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot <br /> line____-______--•__• <br /> ❑ Number of pits________________ _ ___Lining material---------------------- Size: Diameter----------------------Depth------------------ <br /> well_________________ <br /> Distance from foundation materia ______________________ _ <br /> Cesspool: Distance from nearest ____________. <br /> ❑ Size: Diameter------------------------------------- epth-----------•----------------------------------------Liquid Capacity---------------------------gals. <br /> Privy: Distance from nearest well_____ ---- _____-__--___-._.,___-__Distance from nearest building----------------------------,:,.--_-___--- � <br /> ❑ Distance to nearest lot line-----x -------- ----------------------------------------------------------------------------------------------- ------------------------- <br /> Remodeling and/or repairing (describe)__________________ ". <br /> ---------------------------------------------------------------------------•--•4----------------------------------------------------------------------------------------------------------------------------- --------------- <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)--- • ... •. --•-•---••----- - ------•--- --- -------- -- 11I -------------------- <br /> Contractor) <br /> By....... ....:........... . ---------------------(rte)-- ----------------------------------------------------- - <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 /> REVIEWED BY �� ---- ------------------------------------------------------------- DATE .-... <br /> BUILDING PERMIT ISSUED---------------------------_:3_. s' <br /> --------------------------------------------t �L, DATE---------------------- . . ......----•-••-••----- <br /> Alteretionsand/or reco endations: -------------------- -•••-•......••••---•-•••-•-----•---------•--•••-•••-----••-••--------------•••......-•-•--•-•..._... <br /> ........ . ........ _ _1---'•--"'-----"-"------'--'_.__. __.__-._______________..______.._.-._.----•--- -' ___._____. _--.------ r ...... <br /> - ------------------------•------------...-------------------•---.--..... ---------.----------------- ---•---- �......--�.�= -�'-------------------- <br /> ...... <br /> ----------------------------------------------------------------------------------- ----------- -------------------------------- ........•--...............................-----•------------•----------------------•---•---- <br /> ,/ ss . <br /> FINAL INSPECTION BY:. -- ............................. Date---------��... `t.--- --•---•••------------••------•------•-------••--•. <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 />