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APPLICATION FOR SANITATION PERMIT Permit No. <br /> _. (Complete in Duplicate) , <br /> Date Issued <br /> Applica*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_ V_-__ - <br /> Owner's Name---- _=�-... r •-•------------------------------------------------------------------------ -------- Phone------------•--------------•-------- <br /> Address-•---........ --------------- ------------------------------•----------------------------------------------------------------------------- <br /> Contractor's Name----------------------------------------------------- --------------------------------------------------- ----------- Phone------------------------------ - <br /> Installation will serve: ..Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mgtel ❑ Other ❑ <br /> Number of living units: ---/___ Number of bedrooms -_I___- Number of baths __/__- Lot size __--_/ ------------------- <br /> __ <br /> Water Supply: Public system E] Community system [-] Private`�Depth-to Water Table ___- <br /> Character,of soil to a depth of 3,feet: Sand ❑ Gravel E], Sandy,.. oam Clay Loam Clay E] Adobe E]. Hardpan ❑. <br /> Previous Application Made. Yes ❑ No jy"� New Construction: Yes K No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewers is available within 200 feet.) <br /> eptic Tank: Distance from nearest wel#_L_D-----Distance from <br /> _- - fo-u-n--dation-I--__--___-Material__(?_ <br /> No. of compartments----/ _XJ ��-___Liquid depth _.-T ---------. Capacity------ <br /> ­ ­_.. <br /> -Z? 6_ <br /> =�-- <br /> posal Field: Distance from nearest well---- Distance from foundation____-�_d--------Distance to nearest lot line_ ----I.., <br /> Number of lines----------/-----------------------Length of each line-------- A-----------Width of trench_. _ ._._._____--_______ <br /> Type or filter material S'�_}� lC.- filter material___-_/__g__`...________Total length______la_,'S__!_______________________ <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: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- <br /> 171 Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-----------------------_--gals. <br /> Privy: Distance from nearest well--------------------------------------1________-_Distance from nearest building--_-____________-____-_ <br /> EDDistance-to-nearest lot line-----------------------------------------------•----------•-----•------------------------------------------------------•--------------------- <br /> Remodelin and/?r repairing describer:___ .4 1 - ........ ,( --- <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 re lations of the San Joaquin Local Health District. <br /> �•_r ,f-'� w.. -"-r -'- - - -r=err --�:.r -T =xr�c r:-��.,rr�'.�'�^�+.• --�=--'"•;F - � �"-_-�----- <br /> (Signed).... ____________________ _______ _-___-____Owner and/or Contractor <br /> sY= �----'�------ - (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 /> APPLICATION ACCEPTED BY------------------------------ - ---- - ------------------------------------------------ DAT -----/--'_--------------------------------------------- <br /> REVIEWEDBY-------------------------------------------- ------- ------------------------------------------------------ DATE_ --- <br /> BUILDING PERMIT ISSUED---------------------------------- -- DATE------------ --- ------ <br /> Alterations and/or.recommendations---------------------------- '4 --- <br /> ------------------ <br /> ------------------- <br /> " <br /> -------•-•----•--- <br /> -----------•-----------------------•--- ------- ---------------------------- ----------------I--------------- ------------------------------------------------------------------- -------------------------------- <br /> •------- ----------•---------------------------------------- ----- ------------------- ----------- <br /> i�FINAL INSPECTION BY---=-- -- - ---- �;---------------------------------- 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 />