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(� APPLICATION. FOR SANITATION PERMIT Permit No. <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- -----ZZ' -----e-�-- --p---------- ------- ----------------------------------------------------------- <br /> Owner's Name_______ _•__ ___________----- Phone_ _Q�__ <br /> -------------- <br /> - - <br /> ------ ------------ <br /> Address , - d <br /> '•. <br /> Contractor's Name----------•------------------------------------------------------------------------------------------------------------ ------------------ Phone----------------------------------- <br /> Installation will serve: Residence OKApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __t___ Number of bedrooms ---?- Number of baths ---1_ Lot size __F-___ _ - --c____________________ <br /> Water Supply: Public system ❑ Community system ❑ Private [�epth to Water Table , ft. <br /> Character of soil to a depth of 3 feet: Sand Rq_,�'ravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No 29' New Construction: Yes �No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public s wer is available within 200 feet.) y <br /> Septic Tank: Distance from nearest well_ _ Dista cej v m f u dat of_-` _ .Material_ _ _-_-- -- :- <br /> - -- ' <br /> No. of com artments_.-.--- _--__.-_Size__ __ �� <br /> � p �' - ---- -. _ Liquid epQtl�y------�- ��-- --- Capacity---- -8�-----'� <br /> Disposal Field: Distance from nearest well_..© ___ _Distance rom foundation__®rte -Distance to nearest lot line__ <br /> Number of lines_____________/�__________ __..___Length of each line____,?___________'_. 101 <br /> Width of french__a _ <br /> --- <br /> ' Type of filter material______-_____' -----Depth of filter materiaL_.___�_c�fy_____Total length_____________ ----- <br /> Seeps e Pit: Distan o near )I ✓0 ___ _�ista fro fA ation_. � _ Dis to nearest <br /> -Q it - 'g --� ¢ is ter _ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------------------- ____________ <br /> El Size: Diameter--------------------------------------Depth-----_._-----------------_---------------_-----Liquid Capacity-. Is. <br /> Privy: Distance from nearest well----.--------------------------------------------Distance from nearest building-------------------------------------- <br /> 171 Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):----------------- -----------------------------------•-----------------------•----------- ------------------------•------------------------------------ <br /> ----••----------------•-------••--------•---------------------------------------------•----------------------------------------------------------------------- -------- ----------- •---------------------------------------- <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 la and rules an a ations of t San Joaquin Local Health District. <br /> Owner and/or Contractor <br /> (Signed)------------ -- __-� ( / ) <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 R _ _ DATE__ <br /> REVIEWED BY-------------------------- ------------------------ — -- - -- ------------ -------- � <br /> r -------------- - <br /> --- --- --------------------------- ---- DATE------------------------ ----------­------------------ <br /> -- - <br /> BUILDING PERMIT ISSUED--------------------------- --�- ----- ----------------- -- DATE------------------------------------------------- <br /> Alterations and/or recommendations------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -----------------------------------------------------• --------- ------ ------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ----------------------------------- ----------------------- ------- ------------- ------------------------------------------------------------------------------------------------------------------ <br /> ---------------- ----- -------------- - -- -------- ---------------------------------------------I---- ------- ----------------------- y-------------------------------- -------- <br /> -\- <br /> FINAL INSPECTION BY:--- Date '� i ----- ............ ............................. <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 />