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APPLICATION FOR SANITATION PERMIT Permit No.,:� ;--- <br />d <br />(Complete in Duplicate) Date Issued Y", <br />Application is hereby made f,b the San Joaquin Local,Health District for a permit to construct and install the work herein described. <br />This <br />application is made in c6impliance with County Ordinance No. 549, <br />JOBADDRESS AUD-L,@4;A;TION ------------ ----------------------------------------------------------------- -•----------------------- <br />Owner's <br />----------------------- <br />Owner's Name --------------- ------------------------------------ -------- Phone ------------------------------------- <br />Address---------------------------------------------------------------------------------------- _ ------------------------------------------------- <br />_ t --- - --- ----------------------------------- <br />----------------------------------- <br />Contractor's Name ------------- t Phone ------ eyn-n-'rx <br />Installation will serve: Residence g�parfmenf House E] Commercial E] Trailer Court E] Motel [I Other Ej <br />Number of living units' I Number of bedrooms _1----- Number of baths .1----- Lot size ------ I ---- 0771� ---------------- <br />Water Supply: Public system Community sysiterri El Private E] Depth to Water Table -------- ft. <br />Character of soil to a depth of 3 feet. Sand E] .- Gravel El Sandy Loam E] Clay Loam 0 Clay [] Adobe K3 --H- ardpan Fj <br />Previous Application Made: 1Yes D__M_0�11 New Construction: Yes [3—No [1 0 <br />TYPE OF INSTALLATION AND SPECIFICATIONS: <br />(No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br />I")--- ------------------------- <br />Sc Tank, Distance 'from nearest well----------------- Distance from foundation------'_----.--. Material---_-._--.------__-_-- <br />No. of compartments-- --- ------------------- Size-_ -_------------------------ Liquid clep�� ----------------------- .-- Capacity ----------------------- <br />Disposal FieA: Distance. from nearest well_/A;,.*.v_-Distance from foundation ------ -.Distance to nearest lot line -,-47-- 1�7- <br />Number lines------------ Length of each line --- ��nez-ae_-240. Width of trench______;2-_a -------------------- <br />0 4?",length-------------- <br />1 <br />Type , filter material- Depth of filter 'material ---- _Total length -------------- -----_----- <br />07 _V______ <br />Seepage Pit: Distance to nearest well ------------- ----'-_---Distance from foundation-. ------------------ Distance to nearest lot line ----------------- <br />❑ Numbei-Ii1of pits---------------------- Lining material---------------------. Size: Diameter --------- ------------- Dept h ------------- -- --------------- <br />W <br />Cesspool: Disfaric0from nearest well --------- -__Distance from foundation....................Lining material_-..----.--.-----___--.------------ <br />-. <br />aterial------------------------------------ <br />F-1 Siz(�: Di6'meter--,-- ----- Depth ---------------------------------------------------- Liquid., Capacity ---------------------------- gals..,.i- <br />Privy: Distance from nearest well ---------- -------------------------------------- Distance from nearest building--------------------------------- -------- <br />171Disfancdtonearest lot line---------------- ----------------------------- ----------------------- -------------------------------------------------------- ------------- <br />: 6 <br />Remodeling and/or repairiri'b (describe)----------------------------------------------------------------------------- "I ----------------------------------------------------- ------------------- <br />------------------------------------------'"------------------•---•-------•-----•-------------------------------------------------------- ------------------------- ---------------------- I ------------------------------- <br />-------------------------------------------- ----------------------------------- I ---------------------------------------------------------------------------------------------------------------------------------------- <br />-------------------- I --------------------------- II ------------------------ ------------------------------------------------------------------------------------------------------------------------------------------- --------- <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 />I <br />(Signed).--.-------------- --------------- 1 ------------------------------------------ <br />-------------- ----------------------------- - ----------------------------------------- [Owner and/or Contractor] <br />By:__ _--------------•-•-- .. 11 ....... ------------- ------------------------------------------------------------------------------- (Tif le) ---------------------------------------------------------------- <br />(Plot plan, showing size of lot,ii 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 />------------------------- ----------------------- 7 ------------- i ------- <br />REVIEWEDBY--------- ------------------------------------- I ----------------------------------------------------------------- DATE ------------------------------------------------------------ <br />---------------------------------------------------------- -- <br />BUILDING PERMIT ISSUED - ------------------------------------------------------------DATE <br />- <br />Alterationsand/or recommendations:------------------------------------------- ------------------------------------------------------------------------------------------------------------------- <br />---------------------------- I ------------------ ------------------------- ----------- -------------------------------------------------------------------------------------------------------------------- -------------- <br />---- I ----------------------------------- ------------ ------------------------------------------------------------------------------------------------------------ _ ------------------------------------------- <br />--------------------------- ------------------- ------ I ------------------------------------------------------------------------------------------------------- -------------------------------------------- ------ ---------- <br />------- ------------- ------------------------------------------------ <br />--------------------------------------------- -------------------------------------------------------- <br />�j <br />----------------------- -------------- I -------------- <br />FINAL INSPECTION BY: Date_ --------------------- <br />------------------------------------- <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 J0-52 Revised W-2 00 <br />