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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <br /> Applica4ion is hereby made to the San Joaquin Local Health District for a permit to construct and in's'fall the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> ji <br /> JOB ADDRESS AND LOCATION-------- <br /> ---------- ------------------------------------------------ <br /> ---- ---- - ------- <br /> Owners Name--7 ------- <br /> 7---- ---- - sOwners --- <br /> ------------ -- ------------------------------------------ Phone--- <br /> Address-_----------- ------- <br /> ----------- -------- ---------------------------------------------------------------------------------------------------------------------------__---------------_-------------- <br /> Contractor's Name_-__-- ------------------------------------------------------------------------------------------------------- Phone. <br /> ;-------------------------------- <br /> Installation will serve: Residence [Apartment House L] Commercial E] Trailer Court [],—Motel L] Other E] <br /> Number of living units: 'J;Uer of bedrooms .:Z--- Number of ba+ks Lot size -------7_57-k ------------------------ <br /> Wafer Supply. Public syste 1. <br /> M 1;_�C'ommunity system El Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth OL]of 3 feet: Sand Gravel Sandy Loam L] Clay Loam E] Clay L] Adobe [] Hardpan L] <br /> Previous Application Made: 'Yes E] No New Construction. Yes E] No <br /> TYPE OF INSTALLATION �ND 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 /> ------------------------------------ <br /> F1 No. of compartmerils--------------------------Size----------------------------.-.-Liquid depth---------- ---------------Capacity----------- <br /> Disposal <br /> --------------Capacity-----------Disposal Field: Distance from nearest well--------------.-Distance from foundation--------------------Distance' to-nearest lot line___--_______..._. <br /> El Number 0"'f lines-------------------------------- rN <br /> ---Length of each line------------------------------Width of trench------------ ­--------1­ <br /> Type of f,ilter material-------- ----------------Dep+ of'filfer material---------------------.-Total length------------------------------------------ <br /> Seepage Pit: Distance to nearest well---------------------Distance from foundation______-..__________ Distance.to nearest lot line---- <br /> F] Number 8f pits----- ----------------Lining- material material-----------------------Size: Diameter-----------------------Depth-------------- <br /> 117 ­ 7' " - I .............. <br /> --- *)`-Distance from,�oun ation. 1 `Cess o <br /> 01: Disfanceffrom nearesf-well- f ---------Lining material------- <br /> Size: Diameter....... .5-------------------------Depth--------------�7--------------- <br /> Ao ji ------------ ------ ------ <br /> Privy; Distance �Ircm nearest well--------------------------------------- - <br /> ----- ----Distance from nearest building--------------------❑ --------------------- <br /> Distance to nearest lot line_____.___________________________________-_ <br /> Remodeling <br /> ine----------------------- <br /> Remodeling and/or repairing (describe):------------------------------------- ------------------------------------------------------------------- <br /> -------------------------------------------------------------------—-—------------------------------------•---------------------------------------•-------- --------- --------------------------------------------------- <br /> --------------------------I----------------------------- --------------- --------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------It---------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I heve prepared this application and;,that the work will be done in accordance with San Joaquin County <br /> 'y <br /> ordinances, State laws, and roles and regulations of the San Joaquin Local Health District. <br /> (Signed ---------------------------------------------------------------------------(Owner and/or Cont for) <br /> ------------- --------- <br /> ----------- -------------------------------------------------------------------- ---------------(Tif le)------- rac <br /> B ------ --- ------------------------- --------------------------------- ---------------- <br /> (Plot plan, showing size of lo+!'location of system in relation to wells, buildings, efc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------------------- -------- ------ --- ----------------------------I----------- DATE--------- —.5 4-, <br /> REVIEWEDBY---------------------------------------I-------------------------------------------------------------------------------------- DATE -------------------- <br /> BUILDINGPERMIT ISSUED---!I-------------------------------------------------------------I----------------------------------- DATE--------------------------------- <br /> Alterationsand/or recommendations:--------•---------------- ------------------------------------------------------------------------------------------------------------------------------------ <br /> ---------------------------------------------------li------------------- ----------- <br /> -------- ----------------- --------------------------- --- ­------------------------------------------------------------------------------ <br /> ----------I------------------ --------------- ---------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------I----------------------------------------------------------------------------I---------------- <br /> ---------------------- ---------------------------- --------------------------- ------------------------------- -------------------------------------------------------- ---------------------------------------------------- <br /> FINAL INSPECTION BY:__4 <br /> ----------- ----_L/----------------------- ------- Date----------------- <br /> -- - --------------------------- <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-21001 <br />