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APPLICATION FOR SANITATION PERMIT Permit No. ,JA/ <br /> •��--- (Complete in Duplicate) ,G� ,,, <br /> P } SZ <br /> Date Issued <br /> - <br /> .: 1 � � rv.,ate ..•fid <br /> Application is ereby made to the San Joaquin Local'Health'Districtjor a permit to construct and install the work herein described. <br /> This;application is made in compliance wifh County,•Ordin ce No. 549.' <br /> A RESS AND OCATION..___ <br /> h <br /> e44 <br /> ---------- ------------------ <br /> Owner's Name = f ' --•---• - ------ ----- ----------------- <br /> ---.... Phone-------------- --------------------- <br /> - <br /> Address ---•.L---- •-----` ----------------- -- <br /> Contractor's Name_______________________ <br /> ...- ----.- Phone----------------------------------- <br /> Instillation wi[hserve: Residence Ap . meat House ❑ Commercial E] Trailer Court ❑ !Motel ❑ Other ❑ � <br /> Number of living units: __ _ -,Number of bedrooms __Number of baths ___(____ Lot size ._ _ _-- /�..�..- -� <br /> Water Supply: Publicssystem+❑ Commu nity system ❑ Private [ Depth to-Water Table_ __ ft- <br /> Character of soil:+o a depth of 3 feet: Sand �/, Gravel ❑ Sand Loam Cla Loam Cla # <br /> Jam, Y ❑ Y ❑ Y ❑ Acloba ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No9. New Construction: Yes No E-] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 240 feet.) <br /> Septic Tank: Distance from nearest well __SO----.Distance from foundation--/a—---------,Materia _.-__.____ me + <br /> No' of compartments ' SizeLiquid depth -- --------Capacity---- <br /> ��r o <br /> Disposal Fiefd: Distance from nearest well----/i.(,D__._Distance from foundation-----2q_-----.Distance to nearest lot line_______. -. I <br /> Number o1 lines----------/____________ _________ en th of each line______ <br /> 9 3-0 -- .Width of trench------�..- •-'�--....-------- j <br /> Type of filter material-___S� Depth of filter material________. ..___.Total_length_._____- _{ -------------------- <br /> Seepage Pit: Distance to nearest well.=_._�6-----------Distance om fo n t' n_ <br /> y� .,�_�._...Dista,lCF? to nearest lot line_--�.._.___.__ <br /> Number of pits.---• 1 material�L iameter--------•-'��----------Deptn <br /> ------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from oundation--------------------Lining material_____---_._..___. ._ <br /> Size: Diameter--------------------------------------De th---- - <br /> :� �� `. -, _ , ' -- - Liquid.Capacity. --gals: <br /> Privy: Distance from nearest well __.. ------------------_________ ___ ___Ddsfance from near-,,,' building.----------------------------------------- <br /> Distance to nearest lot line '= <br /> Remodeling and/or repairing (describe)--------------------------------------------------------,- <br /> ------------------------------------------- <br /> -----•--------------------------•----------•---------------•---------.-.---------------------•------------•--•----------- <br /> ------------------- <br /> 'I. <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, Sta a laws, and rules and re ulafions of the San Joaquin Local Health District. <br /> [signed}._ -- ------. -- ----------------------------------------------------------- -----------------------------------------(Owner and/or Contractor) <br /> 1 BY:---••---------------------------'--•--------- Title <br /> (Plot`plan, showing size of lot, location of system in relation to wells, buildings, etc., can 11 be placed on reverse side). r <br /> I FOR DEPARTMENT USE ONLY <br /> APPLIICATION ACCEPTED BY---- --------------------------------------------------------------------------------------------- DATE----------- <br /> •-• -- ----------------------------------------- <br /> REVIEWED BY-. _ ----------------------- DATE -� --+ t-r <br /> BUILDING PERMIT ISSUED____________________________ <br /> --------------------•---------. DATE.-----------------------_/ I <br /> Alterations and/or recommendations ------------ - ---------•-••------ <br /> . �--- - _- <br /> T —`'-'-'-�i---'---.-'•----------•--------------- <br /> `------•--'---------------------- --------------------------------------------I, <br /> ti------------------------------- <br /> fi – ­------------------------------------------------------------------ -------------------------------------- <br /> FINAL INSPECTION CTION <br /> �I BY: Date----'------------------------------------ <br /> SAN <br /> � <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> N Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES=9-2M 10-52 Revised W-2100 <br />