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..// <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> V (Complete in Duplicate) 6 <br /> Date Issued ___. .ls'. <br /> Application 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 Coun r i an 5 9. <br /> JOB ADDRESS AND LOCATIO ____ ________ _________ _ <br /> ------- ------ ___/--- ------ --- --- <br /> Owner's Name---- '-'`R --/ - - Phone <br /> Address . ---- --- <br /> -- -------- <br /> ---- --------------------- - -- <br /> !! <br /> Contractor's Name �' - - ==---------------- Phone----• `� 1---2--'[ <br /> y <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: J---- Number of bedrooms _?_ Number of baths •/-_- Lot size ----- Z.._..........I_j ______________ <br /> Water Supply: Public system ❑ Community system ❑ Private 6-15epth to Water'Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobardpan ❑ <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ 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-_1bf___w.Distance from foundation----- _4__--__.Material------ ______________________ _____________ <br /> No. of compartments---------- ��_ _J_4�___Liquid depth_--_C,�_._----.__-____-_Capacity./Q�G------- <br /> Disposal Field: Distance from nearest well.Zad'._'._Distance from foundation----ZsS~_f__.__Distance to nearest lot line---/ ..... <br /> Number of lines-----------/--._,---_-�__+�'�_ Length of each line------- ,_.Width of trench_41 ...... ................ <br /> Type of filter material_ G� 1-------Depth of filter material----� Total length <br /> Seepage Pit: Distance to nearest well---/J__0--- ._Distance from foundation____,,�'�_.f.Distan�ce to nearest lot line.__/0!_-- <br /> Number of pits------./---___-._.--Lining material_l -*..Size: Diameter___.R1 -.. .......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 /> Remodelingand/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, Sta laws, and rules and regulatiRns of th San Joa uin Local H alt District. <br /> (Signed)-- •-•--- --- ---------- ---�-:---- --- ------- ----------- -----------s------ ---------------------------- r a or Contractor) <br /> By:....-... -------------------------- ----------------------------------------------------(Title)--------------------------------------------------------------. <br /> (Plot plan, showing size of lot, location of system in relation to we Is, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- ---------------------------------W-i9lU ------ DATE.------------- ...... <br /> �. j--- --- ------------• <br /> REVIEWEDBY------------------------------------------ -- ---- -- -------------------------------------------------------- DATE-------------------------------------------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE......................... •---------------------------------- <br /> Alterations and/or recommendations------------------------------------------------------------------------------------------------------------------------•---................................... <br /> -------------------------------------------------------------------------------------------------------------------------------••-------------------------------------------------------- ------------------------------••---- <br /> -------------------- ----------------•-------:--------------•--------------•-----------------------------------------------------------------"-------------------------•-----------------•--------- ------------- <br /> ----------------------------------- ------------- ------------ ....... --- ------------------------------------------------------- <br /> FINAL INSPECTION BY <br /> Date------------ <br /> -------------- - <br /> - ---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 10-52 Revised W-2100 <br />