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APPLICATION FOR SANITATION PERMIT Permit No. ...... ._9J....... <br /> (Complete in Duplicate) <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 /> JOB ADDRESS AND LOCATION / 7 /i�`i/�P..-•-•--------------------------•---------•---•-------••-----------------------•----------•.--- <br /> Owner's Name --------------------- - l�t� ---------------------------------- <br /> 19Phone <br /> Address---------------------------------------------------------{-- ----- . . ------------------------------••-•-------------------------•------------------------------------------------------ <br /> Contractor's Name-------------------------------------------5�m ------------------------------------------------------------------- Phone................................... <br /> Installation will serve: Residence Y Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ________ Number of bedrooms -S--- Number of baths _____1_ Lot size -------- ----^________________________ <br /> Water Supply: Public system XJ Community system ❑ Private ❑ Depth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeo Hardpan ❑ <br /> Previous Application Made: Yes ❑ N04 New Construction: Yes 4K 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-----AID------Distance from foundation------, 0---------Material______._ <br /> -- - -- ------------------- <br /> No. of compartments--------------------------Size__-_.S.♦V--_ .......Liquid dept -------------L-________Capacity-_ -r------ 1� <br /> f <br /> Disvi Field: Distance from nearest well------ Distance from foundation..__-;W------------Distance to nearest lot line.-----S..... <br /> Number of lines_______________�T Length of each line__yB: o- 3�3a- _-Width of trench___________'�__f1_"1__________---_- <br /> Type of filter material_______ %�______---_Depth of filter material._._._-Is"________Total length.___-_-___/__ G-._�_________________ <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: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-------------------------------------- d <br /> ❑ Size: Diameter------ ---------- ------------ -------Dept h----------------------------------------------------Liquid Capacity------------...............gals. Ij <br /> Privy: Distance from nearest well---------------_-----------_---------------------Distance from nearest building_____'________:___.---------------------- <br /> ❑ Distance to nearest lot line-------------------------------------------•-------------•-------•---_-----------•-----------------•--------•------------ <br /> Remodeling and/or repairing (describe):......................................................................................................................................................... <br /> -------------------------------------------------------------------•---------------------------------------------------------------------------------•--------------------------------------------------------------=--------- <br /> - - -------------------------•--------------------------•----------------•---------------------------------- ---•-----------------------------------------------•--------------------•----- <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />- <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)---- -e,1-�._ --- ------------------------------------------------------------------------_---------------(Owner and/or Contractor) <br /> By:----------------------------------------•-------------------------------------------------------------------------------------------(Title)------------------------------------------------------- <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 /> 9. <br /> APPLICATION ACCEPTED BY DATE ..r.,,�.�1 � _.. ...--- <br /> REVIEWEDBY -------------------------------- DATE---------- ----------C"'_-------------------------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------•--------------------------------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations---------------------------------------- -----------------------------------------------------------------------•-------•----------•---••----•--------------•--- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------ ---------------------------------------------------------------------------------...--------------------------------------------------- <br /> ----------------------------- ----------=--------------•------- -------------------------------------------------------•------------------------------------------------------------------------------------------------------ <br /> ---------------------------------------------------------- ---- ----------------------- --------------------------------------- ------------­----------••------••----------•----------------------------------------------- <br /> FINAL INSPECTION BY: f� ! �=_ <br /> Date----------------------------------- <br /> S--•--------------------------------• <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 />