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APPLICATION FOR SANITATION PERMIT " Permif No. .__ -_ - . <br /> (Complete in Duplicate) AZ <br /> Date Issued 1 <br /> Applic&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 ' '�1- ------------ 7-- ----------------------------------------------------- <br /> Owner's Name._.- 0 L/ _ .---------- ------------------------------•-----------------------------------•------------ Phone----------------------••-------- <br /> Address---------------- '� .........A -�2. _ '/ <br /> -----------------------------------------------------------------------------------------------------...._..__.. <br /> Contractor's Name --• -- - --- - ---c -----.". r------- .......... Phone_ __V/_'/Zd--- <br /> Installation will serve: Residence 5?[_Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ , <br /> Number of living units: -_/.-.- Number of bedrooms __-�Number of baths _ __._ Lot size _.__, " 15_-.l ________________________ <br /> Water Supply: Public system Imo.. Community system ❑ Private ❑ Depth to Water Table _,CA ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe B, Hardpan ❑ <br /> Previous Application Made: Yes ❑ No �9_New Construction: Yes ®, No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) " <br /> Septic Tank: Distance from nearest wellt <br /> � <br /> _ __�-ia._Aastance from foundation___ _G9______.__.Matenal_. -__e___.__ _ <br /> No. of compartments__..-. ;Z------------- � __ _f�___Liquid depth-----4.Q-----------Capacity__9_4? Q---------- <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line________-_______ <br /> ❑ _ Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- <br /> A <br /> ~ Type of filter material_________________________Depth of filter material--------.--------------Total length------------------------------------------ <br /> Seepage Pit: e to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line----------------- <br /> 171 er of pits----------------------Lining material----------------------.Size: Diameter-----------------------.Depth-----------.--------------------- (� <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-----------r---------_________--_--_-. ` <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------•----- ------------------Liquid Capacity----------------------------gals, <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> n Distance to nearest lot line------------------------------------------- <br /> * N <br /> Remodeling and/or repairing (describe):------------------ -------------------•------------------------------------------•----------------------------------------•---•---------------•----•--- <br /> -------------------------------------------------------------•-----------------------------------------•-----------------•--------••----------------------------------------------------•---------•-------------------------- <br /> I hereby certify that I have prepared this application and that +he 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 /> (Signed) ------------------------------------------------------------------------•---------------------------------------------.(Owner and/or Contractor) <br /> By:-------------------------------------------------------------------------------------------------------------------- ---------------(Title)-------------------------------- <br /> (Piot 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 /> REVIEWEDBY---------------------- ----------------------------------- - - DATE------------------, �. <br /> BUILDING PERMIT ISSUED-------------------------------------- .---- - --------------------------------------------•-•-- DATE--------------------- <br /> Alterations and/or recommendations_______________ -- <br /> ---------------------------------I--------------­-------------------------------------------------------------­­-----------------------------------------------------------------------------A7-----------­---- <br /> ----------------------------------•--------------------------------------------------------------------------------------•---------------------------•-••-------------------------------------------------- <br /> ----------•-----------•----•-------------------------------------------------------------------------------------------------- ---------•---------------------------------------------------------------------------- <br /> -----------------­ <br /> ------------------------------------------------- ----- --------------- ---- -------------- <br /> FINAL INSPECTION BY:- -.------------------------------------- Date----------------------------------------------- <br /> SAN <br /> -----T -------.---- --- .SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M . Revised W-2100 <br />