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APPLICATION FOR SANITATION PERMIT Permit No. ...... 1..•..... <br /> (Complete in Duplicate) <br /> Date Issued C <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 Cou rdi ance No. 549. <br /> JOB ADDRESS AN TI ------- ----.------------ <br /> Owner's Name-------- ------ ---�- - - ------- - -- --------------------- ------------------------- ------------ Phone........vTT=7....-----•--------- <br /> Address--------------- ----- --- -------- •----• ---- --•------------------•----------------•-----•---•---------•--•----- ------------------------•-•-•--------•••--... <br /> Contractor's Name------ ---- -- ---•-. ----- ------ -------.-.-..-..-----------_. Phone----------------------------------- <br /> Installation <br /> ---•--------------------- -----Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ O er <br /> Number of living units: __.I__ umber of bedrooms ----- . Number of baths ---I- Lot size __-' __Q___A-I_ - v <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: San Gravel ❑ Sandy Loam P Clay Loam E] Clay ❑ Adobe Hardpan E]Previous Application Made: Yes [-] No New Construction: Yes o ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if ublif sewer is)available within 200 feetY7�'" <br /> Septic ank: Distance from nearest well&0- e fro fou tion!0 Materi <br /> - .... <br /> of compartments nnt����.�, -�{��Q�_ _.Liquid d�p�th ----------Capacity---- = � <br /> Dispo I Field: Distance from nearest eI Y.�C "'Distance fir f2fundation__!/ ____�!-" Distance to nearest LS t li __ <br /> ;� Number of lines________ _____ _____________Length of each line--------- -- _r Width of trench._._. �51.. ._�t._.______.... <br /> --- <br /> Type of filter mater <br /> t---- <br /> yp --- `?!�1'�-Depth 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: Distance from nearest well----------------- from foundation---------.----------Lining material_____________________________________. <br /> ❑ Size: Diameter----------------- --------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------- <br /> ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------- - <br /> Remodeling and/or repairing (describe):-------------------------------------------------------------------------------- --•-----••---•---•--------•- <br /> ---------------------------------------------- ----------------------------------------------------------------------------------------------- ---------------- <br /> -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---•-------------- - JI <br /> ---------------------------- ------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I have pressystem <br /> lication and that the work will be done in accordance with San Joaquin County <br /> ordina;Vy;:$r <br /> et aws, rules anof the San Joaquin Local Health District. <br /> (Signe -------- / -----------------------------------------------------------------------------------------(Owner and/or Contractor) <br /> ------------------------------- --------- ---------------------------------------------------------------(Title)-----------------------•---------------- ------ <br /> (Plot plan, showing size of lot, locatirelation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ------------- -------------- <br /> REVIEWEDBY----------------------------- -------------------------------- ----------------------------------------- DATE-- <br /> BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------- ------------- DATE-------- <br /> Alterations and/or recommendations:-- ------------ <br /> ------------------------------------ <br /> ------------------------------------- Yy 1 ---- ----------------- <br /> ---------------------------------- ----------------------------------------------------------------------------•-------------------------------------------------------------------- --------------------------------- <br /> -------------------------------------- ---------- ---------- "------------------------------------------------- <br /> FINAL INSPECTION BY:... --------------- Date.-- ' - .-.4 <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 />