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APPLICATION FOR SANITATION PERMIT Permit No. S. -.T.....____ <br /> (Complete in Duplicate) b /� <br /> -r 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............. _ <br /> ---------- !f <br /> Owner's Name---- - -.....* ------------------------------- --------------._­-------------------- ------ --------------- Phone _- - - - <br /> Addressa OCL --------------•-------------------------------------- q <br /> Contractor's Name ----------------------- -----------•--------•-------- ------ ------- Phonel`f'v_ ---L-�-07-- <br /> Installation will serve: Residence [�parfinent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---/--- Number of bedrooms __n2 Number of baths __ ___ Lot size --- �__�_X./_r�.G------------------------ <br /> Water <br /> ----- __Water Supply: Public system D-1-Community system ❑ Private ❑ Depth to Water Table _!2l(j ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 3-lHardpan ❑ <br /> Previous Application Mader Yes ❑ No ew Construction: Yes El 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 /> ❑ No. of compartments--------------------------Size----------------------------•---Liquid depth------------------ ------ Capacity----------- ------ <br /> Disposal Field: Distance from nearest well_________________Distance from foundation-------..__.-------Distance to nearest lot line________.____.__. <br /> ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french_---------------------------------- <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length--------------------------------------/-- <br /> Seepage Pit: Distance to nearest well------�-------Distanc frfj� foJunafion----`2�______.Distance to nearest to line------------------ <br /> 2 Number of its___.___ __Linin materiaL�_`' Size: Diameter.__. .._______..Depth_.__�-�j—________________ <br /> i� g <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------____------------------------------------------------------------- %A <br /> Remodeling and/or repairing (describe):------------------------------------------------------------------------- ------------------ ---------------------------------------------••-------- <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,i and rules and regulations of the San Joaquin Local Health District. <br /> t <br /> -!2 <br /> (Signed)----- = _--- ------ --------------------------------------------------------------- -------- ---------- and/or Contractor) <br /> f ------------------------------ <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---------- - S <br /> REVIEWEDBY------------------------ ---------------------------------------- -------- ----------------------------- DATE------------------ <br /> BUILDING PERMIT ISSUED-------------------------------------------------------------------------------------.---------------- DATE. <br /> Alterations and/or recommendations:------- ----- ---•=----------------------------------------------------------------------•---- -------------------------------------- <br /> --------------------------•------------------------------------------- -------------------------------------------------------------------------------------•--•---------------•-------•-----------•----------------------- <br /> ---------------------------------------------------------------------------------------------- -------•-------------------------------------------------------•------•-------------------------------•-------•---------.----- <br /> - -----------------•-------------- <br /> .-- --•-•-----•---•---------------------------------------•-- -------•- ----------------- .............I <br /> FINAL INSPECTION �'• - <br /> BY: Date__ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfrae+ 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ; Revised W-2100 <br /> s <br />