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APPLICATION FOR SANITATION PERMIT Permit No. <br />vp <br />Applica4-ion is hereby made to the San Joa <br />This application is made in com Ilan "ll <br />�: <br />JOB 'ADDRESS AND-&OCATI,@N <br />TAU— <br />Owner's Nam <br />Address--------- r. <br />Contractor's Name______________ -------- <br />(Complete in Duplicate) <br />Date Issued ---.-A,�J_' <br />lin Local Health District for a permit to construct and install the work herein dq.. ribed. <br />nt rdinance No. 549. <br />JiO " '-------------------------- ------------- <br />�+----------------------------------------- -- Phone--------------- - <br />--------------------------------------•------------------------------------------------------------------- Phone ----------------------------------- <br />Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Moldel ❑ Other ❑ <br />J---- <br />1 <br />Number of living units. --/---- Number of bedrooms _--'-- Number baths -_f ____ Lot size ----------------------- <br />Water Supply: Public system ElCommunity system El Private pth t Water Table ________ ft. <br />Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam Clay Loam El Clay ❑ Adobe E] Hardpan E]Previous Application Made: Yes ❑ No New Construction: Yes No ❑ <br />TYPE OF INSTALLATION AND SPECIFICATIONS: <br />(No septic tank or cesspool permitted if j�b�11�11c s�erv��er is available within 200 ff/e�/}e��A <br />Septic ank: Distance from nearest well--!' "- Dista fro Ifou 4tion_!.i/-__.__�.� ater It. M <br />No, of compartments ----------/til_11___-,---- SJ-�ze � _X_ ----Liquid dep.*h--- ----------.---- Capacity---- - __Q_ <br />Dispose 'reld: Distance from nearest weli§10 "`Distance from foundationj� __'�r�:_.Distance to nearest lot�1*,e �__- Number of lines________ _ _.. __----____ Length of each line--___-___!:�__�f% Width of trench__ __�/t <br />Type of filter mate p iT g al <br />�e th of filter mater�al____.___I_ . ______Total length ___�_______________________ <br />Seepage Pit: Distance to nearest well ---------------------- Distance from foundation -------------------- Distance to nearest lot line_________________ Ip� <br />❑ Number of pits ---------------------- Lining material ----------------------- Size: Diameter ------------.---------- Depth --------------------------------- V <br />Cesspool: Distance from nearest well ----------------- Distance from foundation -------------------- Lining material -------------------------------------- <br />LI Size: Diameter--------------- ---------- Depth ------------------=-------------- ------------------Liquid Capacity------------------ --gals.-' <br />Privy: Distance from nearest well ------- _----------------------------------------- Distance from nearest building ---------- .__._________-_.-.--------____-_ <br />❑ Distance to nearest lot line- ------------------------------ ----------------------------------------------------------------- ------------------------------------------ <br />Remodeling- <br />--------- ------------- <br />Remodeling- and/or repairing (describe): <br />-----------••----••------------------•----------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------- Z <br />tj <br />------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -An <br />I hereby certify that I have prepared this application and +hat 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. 7< <br />(Signed) --------------------------(Owner and/or Contractor) 7 <br />13y-• -(--- _-• •. -• __-- _ -----------------. �.__.__-------------------------------------- (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---- ---------------------------------------------------------------------------------------.- DATE-��...------------------------------------- --------------- <br />REVIEWED BY --------------------------------- - DATE- � j <br />BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------------------ DATE. <br />Alterations and/or recommendations---------------------------------------------------------•-•----------------------------------•------- ------.-.-..------------••------.---------------------- <br />----------------------------------•----------------•----------------------------------------------------------------------------------------------------------------------------•-------•-------------•--------------------.. <br />------------------------------------------------------------------------------------------------------------------------- ------------.---------------------------_----------------------------------------------- <br />FINAL INSPECTION BY ---------------- .--------------------- Date ------! <br />s <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 />