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APPLICATION FOR SANITATION PERMIT Permit No.�-�._ <br /> (Complete in Duplicate) Date Issued �A/4 <br /> - <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and in all the work herei i d. <br /> This application is made in compliance with County Ordinance No. 549. 5� <br /> JOB ADDRESS AND LOCATION.- a,4 five (� <br /> Owner's Name------------------------ 'rl-► - -------------- ---- Phone <br /> Address----------------------- .....-- � I' ----------- <br /> ------------------------------------------------------------------------------------------------ <br /> Contractor's Name----- --------------------------------------------------------------- ------------ ------------------------ Phone----------------------------------- <br /> Installation will serve: Residence IN Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ <br /> Number of living units: __/_._ Number of bedrooms Number of baths .F----_ Lot size ,/ _ __-_-__-__------------------------- <br /> Water Supply: Public system E] Community system E] Private Z Depth to Water Table .Z L ff. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam WL Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: . _ — <br /> (No septic tank or cesspool permitted if publics a available within 200 feet.) <br /> Septic Tank: Distance from nearest well____ _____ istanc rfro ,foun�j-ion__.�lJ_______._.Mat ial_____ _ _________________________ ________�q__�.-'f <br /> No. of compartments-------�__...___/__._.Size-_�X_-7--� _--_Liquid depth____7.............Capacity..- ---- --•� / °` <br /> Disposal Field: Distance from nearest w6l__;?-��_4--Distance from foundation__J.�Q_____E..Distance to nearest lot line-_5------------ <br /> Number of lines__________, _ ----- ____ -Length of each line-------r742__ Width of trench_.__. <br /> Type of filter material-_ i_ Depth of filter material------ _--------Total length___.___..(740-------------------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation___-_________._.__. Distance to nearest lot line_.._____________. <br /> ❑ Number of pits---------I ----------Lining material-----------------------Size: Diameter-----------------------Depth----------------------- ------ ""O <br /> Cesspool: Distance from nearest well-r_______________Distance from foundation---.----------------Lining material-_____.________-_______.__.______.__ r <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity--------------------- ----gals. <br /> Privy: Distance from nearest well __________________________________-------------Distance from nearest building----------------------------------------- <br /> F1Distance to nearest lotline----------------------------------------------- --------------------------------------------------------------------------------------- <br /> Remodelingand/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 /> )--------••---- <br /> 5i ned ------------------------------------------------- --------------- (Owner and/or Contractor) <br /> 9 <br /> B - - ----- ------------------- (Title))----------------------- --- �.. <br /> V0,(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT US ONLY <br /> APPLICATION ACCEPTED BY..... ► ------------ DATE----- v .._?.- --------------------- <br /> REVIEWEDBY-------------------------------------------------------------------------------------- -------------------------------------- DATE------------------------ - <br /> BUILDINGPERMIT ISSUED-------__------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations:----------------------------------------- -- - --------------------•-------------------------------------------------------__------------------------------- <br /> •-----------------------------------------I-------------- ---------------------------------------------------------------------------•------------------------------------------------------------------------------------ <br /> ---------------------------------------- --------------•------------------------------------------------------------ ------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:..____ ._r / �-------------------------- Date------- � � <br /> -�r' - --- -------------------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Streef 300 West Oak Street 132 Sycamore Stree+ 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy. California <br /> ES--9-2M 10-52 Revised W-2100 <br />