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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <br /> ----l-7-1 <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 OrdinanN o. 549. <br /> 0 <br /> JOB ADDRESS AND LO-C -- ----------- ------ --- ------- <br /> �TION..- - ---- -- - - --------- -------------------------------------------------------------- <br /> Owner's Name ------------- - <br /> ----- <br /> Address --- - ' <br /> ---------- --- -------- ------------------------------------ <br /> Contractor's <br /> -----­­---Contractor's -------- ------------------ ---- <br /> Name------------------------- ---------------------- ----------------------------------------------------------- Phone----_', � <br /> Installation <br /> hone------ <br /> Installation will serve: Residence ❑ e <br /> Apartment House F] Commercial El Trailer Court 0 Motel 0 OthOfhr <br /> Number of living units: Number of bedro'oms . __ Number of baths -0--- Lot size - <br /> Wafer Supply: Public system Community system E] Private E] Depth to Wafer Table� <br /> Character of soil to a depth of 3,feef: Sand E] Gravel [] Sandy Loam Ej Clay Loam El Clay El Adob I' Hardpan El <br /> ,2,k <br /> Previous Application Made: Yes 0 N0 New Construction: Y No 0 <br /> 1� eX <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Distance from nearest w)l_—/_1_,i0'�Disfance from foundation,- Material----- <br /> Septic Tank ------- --------- <br /> No. of comparfr ( _Si,el!:�_ -,---Liquid depfh - ----------Capacify.­_��_ ---- <br /> Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line____.-___________ J <br /> ❑ Number <br /> ine----------------- <br /> Number of lines-----------------------------------Length of each line-----_-----------------------.Width of trench-------.--------------------------- <br /> Type <br /> rench----------------------------------Type of filter material------ ------------------Depth of filter material------------------------Total length______________.._-.-..-___-_____________._ <br /> Seepa <br /> ength------------------------------------------ <br /> a e Pit: Distance to nearest ---Distance m fo V----------Distance to neare e____ <br /> Number of pits---/----------------Lining materjiqa�; -Size: &`ameter_._7...............Dept' V_ <br /> ep vdafion <br /> e pool <br /> Distance from nearest well-----------------Distance from foundation ---- ------------- Lining material______.._.___.___-______-____ --- <br /> E1 Size: Diameter__________________ ._-___.____Depth-------------- ---------------------- --------------Liquid Capacity--------------------------- als. <br /> Privy: 1 Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------------------------. <br /> ❑ Distance <br /> uilding------------------------------------------ <br /> Distance to nearest lot line----------------- ---------------------------------------------------------- ---------------------- <br /> Re odelin and or r irin describe <br /> --- - -- - -------- - - ---- ----- ---------- ---------- ---------------- ------- <br /> --- ---- ---------- ------- ...... -------------- -------- -- -------------- -- --------- <br /> - ---- ----- 0 -- ---- --- --- ------- <br /> I hereby certify fha h repared this application a hat the work wl I be done i a ante with San',r;zzin Cou <br /> ordinances, Stated <br /> ,jawA, and I an regulations of the San Joaquin Local Health District. <br /> (Signed)------------ -- ------------ ------------------------------- ---- --- ---------------------------------------- --(Owner and/or Contractor) <br /> By:-------------------- ------ - ---------------------(T - --- ---I---------------------------------- <br /> �;,-- ---------------------------- ---------------------------------------- (Title) <br /> (Plot plan. showing sizeof lot, location of system in relation to wells, buildings, etc., can be p ed o everse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- ------------------------ --- - - ------ ---------------------•------------------------- DATE- <br /> - ' 7-------------------------- <br /> - <br /> REVIEWEDBY--------------------------------- ------ ---------------- ...... --------------------------------------- DATE <br /> ---------- <br /> ----------- <br /> ----- ----- --- <br /> BUILDING PERMIT ISSUED------------• -------------------------- ---- ------------------------------------------------------ DATE---- <br /> ---- ------- --- <br /> Alterations and/or recommendations:------------------------------ --- - - - ---- ------ -------------------------------------------------------------------- ---------- ------ <br /> ------------ ---------------- ---- ----- I" <br /> ------------\-------_ -----_--------------_- <br /> ------------------------------------------------------------------------------------------------------------------------ <br /> ----------------- --- ---------------------------------------------------------- <br /> ------ ---------------------- ---------------------------- ------ --------------------------- - ----------------------------------------------------------------------_-------------------------------- <br /> ----------- <br /> ------------------------------------------------------------------------- --- --- - ----------------------------------------------------------- --------------------------------------------------------------------------- <br /> 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 />