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APPLICATION FOR SANITATION PERMIT Permit No. <br /> ( n� (Complete in Duplicate) ` <br /> Date Issued <br /> Application 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 AIV, LOCATION__��- -- ------------- ------------------�� ------------------------------------- ---- -- ---- ---- <br /> ----- <br /> = <br /> Owner's Name--•---------------- v '� !-,-.-------------.---------------------------- ----------------------------------- <br /> Phone---- ---'7 � <br /> Address-----------;- _ --- -� ��-� �'=�------------------------------------------------------------------------------------------- ---------------------- <br /> Contractor's <br /> -----_------------- <br /> Contractor's Name-------�. ---•-------- Phone------------------•--------•------- <br /> Installation will serve: Resi ence 0' Apartment House ❑ Commercial ❑ Trailer Court ❑ryMotel ❑ Other ❑ <br /> Number of living units: __ Number of bedrooms -_-4__ Number of baths _ __ Lot size _____l_-Q x_ _ _ ----------------------------- <br /> Water Supply: Public system ©Community system ❑ Private ❑ Depth to Wafer Table __ -___ ft. <br /> s <br /> Character of soil to a depth of 3 feet: Sand,❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ r _ <br /> Previous Application Made: Yes ❑ No ❑,. New Construction: Yes [B/No ❑ <br /> t TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> ' (No septic tank or cesspool permitted if�ublic sewer is available within 200 feet.) <br /> x <br /> Septic ank: Distance'from nearest weIlDistance from foundation_ 0_______.-__.Mate <br /> l No. of compartments-----`------------------Size�_'l_�/L'?-1y4;j_"_.Liquid d th--------- --------_--CapacitY--- -Q ----'� <br /> /i 54 _a�.(�4, <br /> Disp�osal Field: Distance from nearest we I istance from foundatia F ___ ,_,__;__�__D.' t e jo nearest jot ling�___. <br /> L"J Number of lines______-._rr ______- Length of each linei _"s:?© - s i th of trench_____ _ _______________.__ <br /> Depth of filter material _�f-_____Total length.----------- <br /> Seepage <br /> Type of filter materi6l �� -_; 1 - <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation_-----------._ <br /> _._..Distance to nearest lot line_________________ <br /> ❑ Number of pits----------------------Lining material----------------------Size: Diameter------------------------Depth--------------------------------- <br /> ' Cesspool: Distance from nearest Well-----------------Distance from foundation <br /> ------------------- material------------ ______--.____.__.___„F•,, <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 /> r -•-•--------------------------------------------------•----•-------•--------•--------- ----------•----------------------------•--------------------------------------------•--------------- <br /> -----• --- <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-laws, and rules and,�regula+ions of the San Joaquin Local Health District. <br /> ` r ---=y�-T- -------- --- -- --- ------= - (Owner and/or Contractor) <br /> (Signed).._ - , <br /> By-------------------------------------- -----------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of Sysem in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION--A---C----:---E-P-T---E- <br /> CCEPTED B ---------------------------------------- ------------------------- DATE�'�._`__----------------- ----------------------- <br /> REVIEWEDBY ---------------------------------------------------------------------------------- DATE C -------------------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------- ------------------------- ------------------ ------ DATE- ---- +------------------------------------------------- <br /> Aiterations and/or recommendations----------------------- -- ------------ -------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------- ----------------------- ------------------------------------------------------- --------------------------------- <br /> ---------- ------'------------------- -------------------------------------------------------- ---------- ---------- <br /> FINALINSPECTION BY:,/_ ©` ---------- Date...... --------------------------------------------- ----------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t <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 9-51 Revised W-2100 <br />