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APPLICATION FOR SANITATION PERMIT Hermit No. . ............ <br /> 0 (Complete in Duplicate) <br /> \Z ` Date Issued ........ <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> 3 e-v �i. � <br /> JOB ADDRESS AND LOCATI - --- ------- --- - - ------ - ----- - <br /> • •. <br /> Owner's Name w '� ...... Phone---. --- •-•-•- <br /> • <br /> Address / f...... <br /> �� �r-- , --- •---. <br /> --------------------- <br /> � ----------- --'� � [ Q Contractor's • � , _ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ........ Number of bedrooms __/__- Number of baths --/-. Lot size __,j----Q--- <br /> Water Supply: Public system ❑ Community system C❑ Private ❑ Depth to Water Table ........ ft. <br /> Character of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam ❑ Clay Loam ❑— Clay❑ Adobe ardpan 0 <br /> Previous Application Made: Yes ❑ No New Construction: Yes 011<00 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if pub is sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well.. <br /> _ 4 . istana from foundation. .......Mate I-• - ----ew� <br /> ---- <br /> WOO— No. of compartments.....(t,,,,.............Sizea . _ Liquid clepth__-4---------------Capacity ---or...4'O----- <br /> Disposal Field: Distance from nearest well�Q-------Distance from foundation•�_10-------Distance to nearest lot line..J40- _>:K <br /> Number of lines._- .----_ __ ��_/ Length of each line............... Width of trench <br /> Type of filter material, _ '4%kf_.Depth of filter material-. 4 length_.___��.lr? .______._ ........ <br /> Type <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: <br /> ---------- ---------.-------- <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 /> -_--_. •--___-__ ••-.._- __.._---- <br /> Distanceto nearest lot line----------------------------_------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):................-------------------------------•-------------------- ----- -•- ----------- -'---- ---------- ----- <br /> - ----------------------••-•• -•-••-•--•••--•-- ••---•---- <br /> =------------ -----------------------------•---------------- -------- .-----------------•---•--------------------------------------- ------------------- ----•- --------- ------ ------ <br /> -- ----- ----- -------------------------------------------- ---- ------- ------ ••----. -•-•-•. ---- <br /> I 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 nd r'gulations of the San Joaquin Local Health District. <br /> (Signed)---- ff9jo-" Q ¢ - `'s '""t' '''e' --- (Owner and/or Contractor) <br /> BY:------- r- !- f e!v --- ------------------------------------------------ ----- -------- -- -----(Tale)---"W44--o- - ' --------------- <br /> (Plot <br /> --- - <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on rewdGe side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- -------- ----------------------------------------- DATE------------------------------------- <br /> REVIEWED <br /> - ---------- ---- _ ---- <br /> REVIEWED BY-- ------------ DATE_ -- <br /> BUILDING PERMIT ISSUED <br /> --- ------------ --- -------_ DATE--- -------- --- ------------------------- <br /> Alterations and/or recommendations-- ---- - ------ - ----- ---- -- ------- -- --- ------ ------•--- ----------------------------- <br /> -----------------------------------------------------------------------------------------------------------------------_---------------------------- ---------------- --------- --------• -•--------------- <br /> - -- -------- ----------- ---- -- ----------------------------- ---------•-----------------------------------------------.......... <br /> FINAL INSPECTION BY:. .{ ------------------ 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 8-51 Revised W-2100 <br />