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1 <br /> 1 1 <br /> APPLICATION FOR SANITATION PERMIT. Permit No.t..I <br /> (Complete in Duplicate) <br /> Date Issued 7t14.4' <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 � ' 3" <br /> Owner's Name. -------- -•----- - ----------------------- ----- ----- ' ! - PhFon <br /> e_ . --- .---.-.- <br /> � <br /> 45! v <br /> ... .Address ` <br /> Contractor's Name--------------------------------------------------------------------------------------- ----------------------------------------------------- Phone.................................. <br /> Installation will serve: Residence [1' Apartment House ❑ Commercial ❑ Tra`iler Court E] Motel ❑ Other ❑ <br /> Number of living units: .I----- Number of bedrooms_.w-. Number of baths _/----- Lot size ........................................................... <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table oZ_-_.a ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam► Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yeses No Rj • New Construction: Yes)E 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_-'�P- -----Distan a from foundation . _O� rial __ <br /> --------------------------------- <br /> A( No. of compartments_----_—-----/--_-__-__Size--�'y-_-.'�'___�-:...Liquid depth...____. .....__....Capacity.-?J.9.......... <br /> Disposal Field: Distance from nearest well ht 0 .Distance from foundation t Distance to nearest lot line ........... ; <br /> [ Number of lines...... ------------- Length of each line-------6pWidth of trench.__.-_'.._._ <br /> Type of filter material.. Depth of filter material...l --__-____-Total length.-a___________ ___________________ N <br /> Seepage Pit: Distance to nearest well _--__-_._Distance from foundation....................Distance to nearest lot line .......... <br /> 0 Number of pits----------------------Lining material.-________-__-___--.-.Size: Diameter------------------------Depth_-____.-___ -_---•-----____--_- <br /> Cesspool: Distance from nearest well-----------------Distance 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)'----- -- ............................................................----------------•-I-----------------•-- ------..,. <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 es and I tions of the San Joaquin Local Health District. <br /> (Signed)------ -�'' -----------------------------------------------------------------(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 /> APPLICATION ACCEPTED BY------- ------------ ---------------------------------------- DATE....?-f�•. --------------------•--•-------- <br /> REVIEWEDBY------------------------------------------------------------------------------------------------------------------ --------- DATE............................................................ <br /> BUILDINGPERMIT ISSUED..................................................................................................... DATE............................................................. <br /> Alterations and/or recommendations:.........................-------------......................................................................................................................... <br /> -----------•---•---•----------------------------------------------------------------------------------------------------------------------------------------------------•-----------------------------------•--------- <br /> FINAL INSPECTION BY:. ----=----------------------- Date.--- ---------- ...... <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-9-21A Revised W-2100 <br />