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APPLICATION FOR SANITATION PERMIT Permit <br /> (Complete in Duplicate) <br /> Date Issued <br /> Applical-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. I <br /> �AJtn--:---- _t.V�--••-•--�----{------------•--------------•---------------------------------•----- <br /> JOB ADDRESS AND LOCATLON....... '� .---------�---------- <br /> T <br /> Owner's Name------------------------�'4''` f- 44 ----------- =:-.-,_----------------------- ------ Phone--------------------•--•--- <br /> Address---------------------------------------------------------•----------------- �jjs--a/"-�.---------------------------------------------------------------------- <br /> el- <br /> Contractor's Name......E--------------- -- -`�_--` -- -------------------------------------------- Phone----------------------------------- <br /> - <br /> will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ------------------------------------------------------------ <br /> Water Supply: Public system E) Community system ❑ Private E] Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam,❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No 0' 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 well________________Distance from foundation--------------------Material------------------------------------------------- <br /> ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation_____---________.--_Distance to nearest lot line________________- t <br /> ❑ Number of lines----=------------------------------Length of each line------------------------------Width of french----------------------------------- <br /> Type of filter material_________________________Depth of filter material------------------ ____Total length______________-_____-_-_-____.__________-_ <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----------.---1__-..Lining material------------------------------------ <br /> ._. <br /> Size: Diameter Depth ----------------- ---Liquid Capacity----------------------------gals. O <br /> ❑ E �s <br /> Privy: Distance from nearest well_________________________________-_--_________Distance-from. nearest 6ui.1ding--------------------------------- <br /> . _ �;_ <br /> ❑; Distance to nearest lot-line------------------ ----------------------------------•---------�n�-r----------------C�-(. �-,------------------------ --------- <br /> -- <br /> ------- ` <br /> �/. <br /> —?y Remodeling and/or repairing (describe):--- 1 l ' ----_-- r -•-•------•----•-•----------- a <br /> • ------------ <br /> ----- ---•----------------------- = •-•- -- <br /> A_ <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 regulations of the San Joaquin Local Health District. <br /> ------------------------------------------------(Owner and/or Contractor) <br /> (Signed) - ' -- ------------ -------- --------------- ------ <br /> - t <br /> i <br /> Title <br /> ------------------- ---- --------------------------------------- <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----- -------- ----------------- <br /> -------------------------------- DATE---------- <br /> - ---- -------- <br /> REVIEWED BY---------------•--------------------------- ------ ----�---- <br /> DATE--------- Y <br /> BUILDING PERMIT ISSUED-----------------'-------- ------------------------------------------------- DATE----------------------------------------------------- <br /> - <br /> Alterations and/or recommendations:------------------- .-------I-----------•---------------------------•--------•--•--••----------------------------•--- <br /> ---------------------------------------­------------------------------ <br /> ---------------------------------------- <br /> ----------------- C ---------- 'r�------- --------- -------_-------------- <br /> --------f�ti fir-c 3-}ate --------- 7 ----------- :[JS ------------- <br /> ----------------------------------------------------------------------- <br /> -----------------I---------------------------------------------- <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 />