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APPLICATION FOR SANITATION PERMIT Permit Nd,.�-_liibed.. <br /> (Complete in Duplicate) sj <br /> lJ� ! 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 des <br /> This application is made in compliance with County Ordinance No. 549. - <br /> JOB ADDRESS AND LOCATION__._!'_ _. .___.- ,____ -+ ' _____________ _ <br /> . <br /> Owner's Name.---- "� ..... ---•--•• -- ------------------------------------------------------------ --------- Phone..........................---------- <br /> Address-------/lp----`-S--4--•-- <br /> Contractor's Name--- •-- -: Phone. ���' _ <br /> Installation will serve: Residence ❑ `Apartment House ❑ Commercial eTrailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ________ Number of bedrooms --------- Number of bathe_ Lot size --- ----------------------------- <br /> Water <br /> .- - <br /> Water Supply: Public system [r'-'Community system ❑ Private ❑ Depth tou,Water Table Ufa_ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [ Clayk Loam ❑ Clay ❑ Adobe[Hardpan ❑ <br /> Previous Application Made: Yes ❑ No �ew 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 /> SepticTa Distance from nearest well_-1­6 Distance from founds+ion___! __.Maters I k ------------------•-_._.._._______ � <br /> gr No. of compartments_..._c�---------------Size__��.6..�_y!-_Y n Liquid depth---__`;-_.>-----------Capacity.... `---- <br /> Disposal <br /> _ <br /> Disposal Field: Distance from nearest well__`! ..._Distance from foundation.__,-F'o---------Distance to nearest lot line--?!!........ <br /> Number of lines_________ _________ __ Length of each line----_l1._4�_--------------Width of trench___�_y H____._....____...� <br /> Type of filter material_S _� ___Depth of filter material _.. ........Total length-------.lo__10.......................... <br /> Seepage Pit: Distance to nearest well_--------------------Distance from:foundation....................Distance to nearest lot line-------_-_--___-- <br /> ❑ 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 <br /> .___..-----._•;-__.-_--___- -__-_.Distance to nearest lot line----------------=----•-----------------•------- --------------------•- ---------•------------------------------------------------------- <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 aws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) ° . 'i ._ ._�-. _:_._._.... wne nd/or Contractor) <br /> By:...................... mac - -��em <br /> (rifle_ <br /> --------------- --- ----- ------- - <br /> (Plot plan, showing size of lot, location of syn eels n to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- -- --- -- ------- :fit DATE , <br /> REVIEWED BY----------------------------- DATE----- . . ... <br /> BUILDINGPERMIT ISSUED.........................................-......................................... ----------_----- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations:-----------------------------------------------------------------------------------------------------------------------•........•------------------------------ <br /> -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------............................................... <br /> ------------------ ------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- •---------•-•-•-- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------- --------- ----------------------------- ----- ------ ------------------------------------- ----- --- ----- ................................ <br /> 7 { <br /> FINALINSPECTION BY-------- - ----------------------- f? ---------- Date--------------------------------� ­------------­-----....................... <br /> SAN <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-2100 <br />