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APPLICATION FOR SANITATION PERMIT Permit No. ..... - -- -------- <br /> (Complete in Duplicate) <br /> Date issued 9ys�-- <br /> Applica-lion 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 OrdinanceNo. 549. <br /> JOB ADDRESS AND LOCAT,ON----------- 1 0 _____,_ -. <br /> : --------------------------------- ------------------ <br /> Y�dn" <br /> Owners Name------ -' ' `�'•�i(aJ`�------------- P e "' - z7 ' <br /> Address................. ----------------1�-•-•--�:* --------------------------------------------•------- ----------------------------------------------------------------------------------------•----- <br /> -� <br /> Contractor's Name..........A ,�✓ r --------------------------- <br /> ----------------------•- ----------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence,q Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _!_____ Number of bedrooms . Number of baths •1____ Lot size _y _ _- _ <br /> Water Supply: Public system S4 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 ❑ Adobe;o Hardpan ❑ <br /> Previous Application Made: Yes ❑ No 54 New Construction: Yes)N No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septieffi�r�k.� Distance from nearest well_________________Distance from foundation--------------------Material-__-___________-----____.______---_____-_____. <br /> yt, 1 / No. of compartments--------------------------Size------- -----------------------Liquid depth--------------- - --------Capacity---------------------- <br /> Dispos i Fiela: Distance from nearest we'll_________________Distance from foundation--------------------Distance to nearest lot line-______________ <br /> } ] I ro INumber of lines-----------------------------------Length of each line---------------------------_Width of trench-------------------,--------.--.--- <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length__---_________-_--_.______________---._. <br /> Seepage Pit: Distance to nearest well ---Distance f.om foundation__:�A-------------Distance to nearest lot lirta__�4-�__.___- <br /> Number of pits------/---_--------Lining material___------Size: Diameter__.-�6__..._..___.Depth__10--------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------._________--__ r <br /> ❑ Size: Diameter------------------------------ -------Depth---------------------------------- ----------r------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------_-----_-----------------------------------Distance from nearest building----------------------------------------- AIN <br /> ❑ Distance to nearest lot line--------------------------°------------------------------------ <br /> �� <br /> Remodeling and/or repairing (describe=----- --------------- -------------------�------------- -------------------r---------------�1 --------------------------------------- ti <br /> I <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, St ws, a u and regulations of the San Joaquin Local Health District. <br /> (Signed)..... . -.. - --- -------- -------------------------------------------------------------- ----- -- -�-_Owner and/or Contractor] <br /> - <br /> sy:. --- .-._l�� - ------------------------------ --------------------{Title) -- � <br /> - ------------------ <br /> (Piot plan, showings of lot, location of system in relation to wells, buildings, etc., can be ced o reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------------- ---- ------------ - --------- ------------------------------------------------ DATE-- -- - -------------- <br /> -------------- <br /> REVIEWEDBY------------------------------------------ -- - -- --- ---------------------------------------------- ----------------- DATE = <br /> BUILDING PERMIT ISSUED--------------- ----------------------------------------•-----•-------------- DATE <br /> Alterations and/or recommendafions---------------------------------------- ------ -------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- <br /> ---------------------------------------------------------- <br /> _­---------------------------•--.-------------------------------------------------------- -------------------------•-•------------------------------------------------------------------------------•--------------_...- <br /> -----------------------------•----------------------------------------•---------- -----------------------------•-------------------------------- -• ------------------------------------------------------------------------ <br /> SLy <br /> FINAL INSPECTION BY -- <br /> - ------------� h4w--- ---------------------- 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 />