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r L <br /> APPLICATION FOR SANITATION PERMIT ±P_prmif No. _- .'�?....-- <br /> (Complete in Duplicate) �,�'Date Issued/--12--'--..._--.-- <br /> Amade 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-- d D--------------" ---------4_1---- <br /> Owner's <br /> Name--------------------------------------------------------------------------- - <br /> Address. ° y ----- ---- <br /> q <br /> Contractor's Name--------- ---- •------ ------ ---- --- ---------------------------------------------------------•----------------•----- Phone/0_ ____l_ _02 <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> yy <br /> Number of living units: __j--- Number of bedrooms __A_ Number of baths -1_-. Lot size 4�Q....._- /l---Za_�q__,_______ <br /> Water Supply: Public system ❑ Community system ❑ Private [EK"Depth to Water Tabled ff. 0 <br /> Character of soil to a depth of 3 feet: S;�New <br /> Gravel El Sandy Loam E] Clay Loam E] Clay E] Adobe�ardpan E]Previous Application Made: Yes E] No Construction, Ye ❑ No 2 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 eet.] <br /> Septic Tank- Distance from nearest well-----------------Distance from foundation--------------------Material --.__.-___----__-------------------------____- <br /> 04No. of compartments--------------------------Size-..-----------------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal Field: 0 Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line-------_---_.--. <br /> ❑ A�aq Number of lines-----------------------------------Length of each line------------------------------Width of trench---------------------------.- --._- <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ <br /> / ♦ ♦ <br /> Seepage Pit: Distance to nearest wel!_----tD- ----------Distance fro fou ation------_----e_------Distance to nearest lot line_______________ <br /> Number of pits------ -------------Lining material e----_t-____ Size: Diameter-_--�J---------Depth..-- �-----_-------__--__ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---------------Lining_materia----------- ----_----_------------_-- '~ <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 /> ---------------------------------------------------------------I­--------------------I......1­1.1----- <br /> ----.-.-----------------------------------------------------------•----------•------------------_-.-....-----------------•__I...........••----_ ..........._.r--------•------------•- <br /> 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,_.,gqd rules and regulations of the San Joaquin Local Health District. <br /> (Signed) ----------------------------------------------------------- (� 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 13Y-;------------------------------------------------------------------------------------------ DATE,----------------- --------------------------------- <br /> REVIEWEDBY---------------------------- ----- - ------------------------------------------ ----------------------------------- DATE- -----------------------------------------•- <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------ .. !_ <br /> Alterations and/or recommendations:----------------------------------------------- .........---------------------------------------------------------------------------------•-- <br /> f– •---------y <br /> J -• <br /> ------------------------------------------------------------------- <br /> L <br /> -------------------------- ----------•------------------------------------------------------------------------------------------------••-------------------------------------- ----`- --------`--------•--••- <br /> ----------------------•----•---•----------------------------------------------------------------------------- --------------------------------------------- -----•-------------- # <br /> J;------------------------------------- <br /> /Z/ <br /> FINAL INSPECTION BY:-------------- ------------ <br /> --- � -- --f ------------------•-•-•---- <br /> -- Date <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 />