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APPLICATION FOR SANITATION PERMIT Permit No..�_ir_ <br /> (Complete in Duplicate) �o l - <br /> Date Issued ._____!./..__�••�____. <br /> Applica�ian 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. 54,9,.,, <br /> JOB ADDRESS AND LOCATION.... C: Y . �!rt.�_.t _ .:� ------- __��_--- <br /> 4 <br /> Owner's Name--------------- - - - Phone--- ------------------- <br /> Address ------------•-•--------•--•---------------------------------------------------------------- <br /> ___________________E____________________________________...__..________________..__._._ <br /> Contractor's Name------ "7� Phone------------ ---------------------- <br /> Installation will serve: Residence ❑Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [❑ Other [❑ <br /> Number of living units: ----I-- Number of bedrooms ________ Number of baths __ ___ Lot size ___ -.�`____ "�_______c____-_ <br /> Water Supply: Public system ❑ Community system ❑_Private,❑ Depth to Wateg.Table -------- ft.. <br /> Character of soil to a depth of 3 feet: Sand ❑ Grave-1-❑ Sandy Loam a Loamt❑ ,Clay E] Adobe E] Hardpan ❑ <br /> Previous Application Made: Yes ❑ No Qom" e1�1e, Construction: Yes rj N <br /> r F <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: i <br /> (No septic tank or cesspool permitted if public�sewer is available within 200 feet.)w ; <br /> Septic Tank: Distance from nearest well, (___ _-.Distance from foundat'on__ F/0.__'___.MateriaL___ _________: <br /> -------- <br /> No. <br /> ---- <br /> No. of compartments_____...___-Size__ _ _ -' _Liquid depth__________ ______________Capacity__. _ _ . _> <br /> Disposal Field: Distance from nearest well- -_-"_Distance from foundation----- --------Dis nce to nearest lot Eine__._.__ _ . <br /> Number of lines-------------r-----------__ ___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______ R_ '_.Distance to nearest lot line__ _-_— ------ <br /> ❑ Number of pits.---------------------Lining material------------_---_ -__-Size: Diameter'-------- ------Depth--------------------------- <br /> r <br /> Cesspool: Distance from nearest well----------------:Distance from foundation--------------"_.--.Lining material-________________.,________________. <br /> ❑ Size: Diameter--------------------------------------Depth---- ------------------------E ------Liquid Capacity. ­­11-------------- gals. <br /> Privy: Distance from nearest well___.___________________________ ___------ -----Distance from inea�rest building--------------------------------------- <br /> ._. i <br /> Distance to nearest lot line______________________________ _ <br /> El: -------------------------------------- <br /> Remodelingand/or repairing (describe):------------------------------------- ----------•---•-----------------------------••----------------------....:.._....--------:....._..------........ <br /> -------------------------------------•-•--------•----------------------------•---•-----------------------------------------------------•---------------•------------------------------------------------------------------- <br /> I <br /> _ 1 <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 <br /> /and regula ions of the San Joaquin Local Health District. <br /> ------ - _________-__Owner and/or Contractor(Signed) / •--------------------- ------ <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------------------------------ <br /> ------------------------------------------------------------------- DATE------------ <br /> REVIEWEDBY---------------------------------------------- ------------------------------- ------------ DATE--- --------------------•-------------------------------- <br /> BUILDING PERMIT ISSUED---------------------------------------- ----------------- DATE- ---- ------------------------- ----------------- <br /> Alterations and/or recommendations_________ ___ _ -`- - ---_-------..-._ ......mak:..-________________ <br /> -v ---------------- ---------...---------------------------------------------------- <br /> R <br /> �- <br /> -------------------- -------------------------------- •-------------------------------------------------------- »...------------------------------------------------•----------------- ------------------------------ <br /> FINAL INSPECTION BY:.- -----•---- Date------//---------7---- -----�------------------------------- <br /> ---------------------------------- <br /> �SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> i <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />