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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issue ------••----=---------- ' <br /> Applica4ion 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 Na 549. <br /> -------------------------------------------------------------------------------- <br /> r r <br /> JOB ADDRESS AND L ATION._-. tf-- - f <br /> 0 <br /> Owners Name----------- .-- - ----- - - --- - -- - --------- ------- - ----------------- Phone-----------------------------------eIL <br /> - <br /> Address _ --- -------_•- ---------- ----------------- <br /> -- <br /> _------------ <br /> Contractor's Name--- -- ------ ----- - ------------`--- =- ---- -----/ -Phone a• <br /> X2r i <br /> Installation will serve: Residence .. Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __1--- Number of bedrooms ,7- Number of baths _-�__ Lot size ____ --__ -1-- --------- <br /> Water Supply: Public system El-_'Community system ❑ Private ❑ Depth to Water Table /ft. <br /> Character of soil to a.depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ •Clay Loam ❑ Clay ❑ AdobeHardpan ❑ <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes No ❑ <br /> f F <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> }(No septic-tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tan istance from nearest well-----------------Distance from foundation--------------------Material------------.-------------___�__---------------- <br /> E*4.0eA9o. of compartments Size Liquid depth- - C <br /> D;sposal <br /> Disposal field: istance from nearest well-----------------Distance from foundation-- -----------------Distance to nearest lot line----------------- A <br /> ®� f„ <br /> tuber of lines---------------------------- ------Length of each line-------------------------- .-.Width of trench----------------------------------- <br /> Type <br /> ------------------------------Type of filter material--------- ------------ - epth of filter material--_-__--------_:----Total length-.-.-_-_-----_-_.._.__----------_---. . <br /> 4 ���� <br /> Seepage Pit: Distance to neares well_,lrh--,-.--__---- istance from foundation_ n <br /> UV : ____.---.Distance to nearest lot line--- 4�-_---_ G <br /> c-- Dept z `�-------------- <br /> �'� Number of pits-_ --__---_--- -_-Lining material-f��Mfundafion <br /> Size: Diameter----icST, -.-_- p Cesspool: i}istance from nearest well-----------------Distance f --.____----- Lining material-------------------------------------- <br /> Cessp' <br /> Size: Diameter--------- --------------------Depth------------------------------------_ ------Liquid Capacity-------------------------- gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance-from nearest building------------------------------------------ <br /> ----------- <br /> Distance <br /> ----------- ____.-_--_-__------------. <br /> ❑ Distance to nearest lot line--------- �----- -=-------- ----------------------------------:�------ ----------- <br /> ----------------------------- <br /> d- <br /> -------- e� <br /> Remodeling and/or repairing (describe)----------- ---- -•----- / --------------- <br /> ---- <br /> I -------x <br /> ----- - <br /> -------•- .._... �. <br /> --- ------------ - - ----------------- ----•--------------------------------------------------•---------------------•--------- <br /> - ---•--------------------------•------•---------------•...- •-- --------..--------•---------------•--•------•-•------------- ----------------•------...__., ------•---------------------------------- <br /> I -- <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Stat laws, and rules an regu tions oft San Joaquin Loca Health District. <br /> � <br /> _ ---- and or { <br /> (Signed)---- {Ow / ontractor) <br /> By:_�es..., ---------------------------------------------------------(Title) I <br /> jr1ot <br /> -------------------------- --------------------------- <br /> [Plot pian, 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-S:- - -- ------- ---- - DATE <br /> IREVIEWED BY------------------------------- Z----------------------------------------------------------------------- ---------------. DATE--- ------------------------------------ <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-----------�............................................ <br /> f Alterations and/or recommendations-------------------------------------- -------------------•---------•-----------•-------------:_:------••-------=---==-----•--------------------.....,,-------• <br /> f ------ --------------•--•---•-••-------.-.----------••------ •- <br /> ------------- -------------••---------•-------•-----------------•------- <br /> h ---"-"-----"---""--•"-----"----------`- "-----"------------------------------------------------•-----------.-.---------- <br /> -----------------------•------- -----------------------------­-••--------------- <br /> FINAL INSPECTION BY:----- -----(J ? ------ 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 Revised W-2100 <br />