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APPLICATION FOR SANITATION PERMIT Permit No. <br />` (Complete in Duplicate) <br />Date Issued ._/_4 3/s= 5r <br />Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work he described. <br />This application is made in compliance with County Pfdinance No 549. <br />JOBADDRESS A LOCATION--- ---- --- C--------------------------------------------------------------------------------- <br />Owner's Name ------ r s A \ ----------- Phone <br />Address__________ ! <br />Contractor's Name___ <br />----------------------------------------------------------------------------=--------.....-------- Phone ----------------------------------- <br />Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑/ Motel ❑ Other [INumber of living units: __�_Number of`bedroomsQ-.- Number of baths _1..._ Lot size _.. ---q __%�.3__�-a__________--------------- <br />Water Supply. Public system [ /Community system ❑ Private [Depth to Water Table ........ ft. <br />Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br />Previous Application Made: Yes ❑ No 2+ New Construction: Yes 2( No ❑ <br />TYPE OF INSTALLATION AND SPECIFICATIONS: <br />(No septic tank or cesspool permitted if public sewer is available within 200 feet.)/ <br />Septic ank: Distance from nearest well.op-------- Distance from,found t*on______ _________.Mate/rj'a�__ t-c'�_ .L"ke ''..______._.. <br />Iy No. of compartments_-_- � ----- f.__ Size %f _ Q__.6___Xs _ Ligaid depth________ T __.___.___.Capacity___ __ <br />Disos Field: Distance from nearest well____ .--_:._ Distance from foundation_?___/____ Distance to nearest to I <br />Number of lines___________ __ Length of each line ----------- ��._{_ ��---- Width of trench..___.____. __.__. <br />Type of filter materi ,_ epth of filter material __.____..U_______Total length ___________%____---------------- <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 to nearest lot line ---------------------------------------------------------- -------------•--------------------------------------------------------------- ---- <br />Remodeling and/or repairing (describe):-----------------------------------............................................................ -- <br />------------------------------------------------------------------------------ .......... .................................................................. ---------------------------------------------------------------- <br />1 hereby certify that 1 have prepared this" application and that the work will be done in accordance with San Joaquin County <br />ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br />(Signed)------. / ...... 1=------------------------------------------------------------------------------------------------(Owner and/or Contractor) <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 />APPLICATIONACCEPTED B--------------------•----------------------------------------------------------------------- DATE- �------ <br />REVIEWED BY ---------------------_------ <br />-- - ---------------------------------------------------------------------------------- DATE.-- ------------------------------------------------ <br />BUILDINGPERMIT ISSUED ...................................................................................................... DATE ......... 4(/\------------------------------------------.._. <br />Alterations and/gr.recoymenAtions:.---------,e—-------„-----------------------f-$--------------- -------::: ------4-N------------,----------ae, .............. i -I........... <br />130 South American Street <br />Stockton, California <br />ES -9-2M Revised W-2100 <br />----------------------------------------- ----•--.....------------.................... -------- <br />� <br />Date./7— <br />------------------------- <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />300 West Oak Street 132 Sycamore Street 814 North "C" Street <br />Lodi, California Manteca, California Tracy, California <br />