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APPLICATION FOR SANITATION PERMIT Permit No. ."J "/.�___ <br /> (Complete in Duplicate) �[ <br /> Date Issued _1/9 S <br /> Applica-1-ion 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 County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION_.=_---" [� - <br /> - <br /> Owner's Name-------------=--•--------------•-----=-----••-------- .; <br /> --------- Phone-------------------- ------ <br /> Address"_: -------------•---------••-'3 2_'3_4---- <br /> Contractor's Name---=---•-----...---•--------- ---••----•------------•---•-------------------- <br /> -=---•- -----------• -------------------------------- Phone----------- <br /> - -• --- -----••---------------- ----- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> t � . <br /> Number of living units: __------ Number of bedrooms -------- Number of baths -------- Lot size <br /> Water, Supply: Public lsystem' -----------------,[ Community system El " Private El "Depth' -------- <br /> to Water Table ft. ) <br /> Character of soil to a depth of 3 feet: I Sand ❑ Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe_S4- Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes ❑ No &L <br /> TYPE,OF INSTALLATION AND SPECIFICATIONS: <br /> ` (No septic tanVor cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation_---------__-".---.Material-_-----_" <br /> El <br /> # Size---------------- ---------------Liquid depth--------------------------Ca Capacity Y <br /> No. o com artments""-_--"."-_.."."_-__".-"" <br /> ----------------------- <br /> Disposal Field: Distance from nearest well-----------__-._'Distance from fdundation : <br /> --------------------Distance to nearest lot line___.-------__-" <br /> ❑ N�mber of lines ---------------------------Length of each line---------------------•--------Width of trench. ("�� <br /> Type of filter material--------------------------Depth of filter material-----------------------Total length------------------------------------------ W <br /> Seepage Pit: Distance fo nearest'well------------------- Distance from foundation------------------..Distance to nearest lot line""___"_ """"""_ <br /> ❑ Nu'mber of pits.----------------------Lining material----------------- -----Size: Diameter - Depth <br /> Cessool: Distance from nearesfweil-----------------Distance from foundation---- . <br /> T - --------------Lining material-------------- <br /> ,Size:_,Diameter. .. _ <br /> .r <br /> 14 <br /> Depth -----------------------Liquid Capacity----- ......... gals. <br /> - - :- <br /> Privy., Distance from nearest +yell""""_...: - �) <br /> _ ---.-Distance from nearest building----------- <br /> 9 ----------------- <br /> Distance to nearest,lot line------------------- <br /> ------------------------- <br /> ----------------------- <br /> - ---------------------------- <br /> Remodeling and/or repairing {describe]:________ _ _____ __ <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 laws, and rules and regulations of the San Joaquin Local Health District. <br /> S ° 4 <br /> (Signed) --------------------- <br /> ------ -------- '-- <br /> ------------=--------------------------------------------------{Owner and/or Contractor)----------------- -- <br /> -- ------------- Title)- •-- <br /> , <br /> By:----- <br /> w <br /> (Plot plan, sh ing size of lot, location o system in relation to wells, buildings, etc., can be placed on reverse side). <br /> i FOR.DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 1 - DATE"_. <br /> - ------------------ ------ - <br /> REVIEWEDBY - ---------------------------- -- - ---- ----= ----------- � ------ DATE---------------- <br /> t--��-� - / <br /> ------------------=------------------- <br /> BUILDING PERMIT ISSUED---------- -------t-- _ - ----------• -- <br /> ------------------ = DATEAlterations and/or recommendations: - ----- <br /> ------- W-a-1-k � a-i.... d ._ • -- -- ----- <br /> - - ------ <br /> ---------- <br /> ---- --------- <br /> ----c=��. <br /> -----------•---- <br /> Ir <br /> --------------•- <br /> --------------------------------------- <br /> ----------------------------------------- <br /> FINAL INSPECTION ---- ----------------- <br /> Date.. tj <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 />