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APPLICATION FOR SANITATION PERMIT Permit No. __ -- - -"� <br /> (Complete in Duplicate) <br /> " Date Issued <br /> Application 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. <br /> JOB AbDRESS A D LOCATION------21,46-Z-------------------- <br /> � ��'r <br /> --------------------------------- <br /> Owner's Name ✓c�`.----------------------------------------------------------------------------------- OO.i <br /> Address--------- _. 1 ?- ------- --------------------------- - - <br /> Contractor's Name-------;,��_ ----------------------------------- Phone-------------------- <br /> ------------------------------------------------ <br /> Installation 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 Community system ❑ Private ❑f Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam 0 Clay ❑ Adobe ❑ Hardpan E❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes ] No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: '' tt <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic-Tank: Distance from nearest well---m� a'_-Distance from founr ation----O--------Material---'-? - _ <br /> No. of compartments_______ ---------,_----Size--- _.�-s_� ..-_ _Liquid depth----;_ <br /> Disposal Field: Distance from nearest well_-- U_-"---Distance from foundation__-_b__ ------Distance to nearest.�t fine__!C________ <br /> ' Number of lines------/I------------------------Length of each line------?A--,-------------.Width of trench-3------: <br /> i �-------------- <br /> e 1 i <br /> R,. Type of filter matrial_-ct Depth of filter material______-�g Total length_____,____.____-------- N <br /> Seepage Pit: Distance to nearest well______________________Distance from foundation____-_____________ Distance to nearest lot line <br /> A _________________ <br /> ❑ Number of pits----------------------Lining material----------------------_Size: Diameter------------------------Dept h----------------- <br /> --------------- <br /> .,Cesspool: Distance from nearest well-----------------Distance from <br /> f' ❑ foundation___",__.-________"_.Lining material------------------------ <br /> Size: Diameter ------------- <br /> ---------------------------------------Dept C <br /> ua aci ---------gals. <br /> Privy: Distance from nearest well-------------------------------------------------_ <br /> __ -Distance from nearest building <br /> ❑ Distance to nearest lot line-'-­ <br /> Remodeling <br /> ine--Remodeling and/or repairing (describe)______________________________________ <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 re tions of the San Joaquin Local Health District. <br /> (Signed)-_�--- <br /> By----------------------- ------- -------------------------------------------------------------------• ---------(Owner and/or Contractor) <br /> ---------------- <br /> ------------------------------- ---------------------------------------------------(Title)-=------------ <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------- --- ---------- ---- ----------------------------------------------- ---------- DATE---� ��~ ` <br /> -- ----------------------------------------- <br /> EDBY---------------------------- -------------------------------------------------------------------------------------------- DATE------------- ------------- <br /> - - ---------------------------- <br /> DIN PERMIT ISSUED-----------------------------•-------------- ----------------------------------------------------I— DATE-- <br /> Alterations and/or recommendations:_"________________ <br /> --- <br /> -------•---------------------------------- -------------- ----------•--------- <br /> FINAL INSPECTION BY:_ ----------------------- f <br /> ---- Date J- <br /> - -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C' Street <br /> Stockton, California Lodi, California Manfeca, California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 <br />