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✓ ``//� 3 <br /> APPLICATION FOR SANITATION PERMIT Permit No. .`7.... .......... <br /> (Complete in Duplicate) <br /> ". I Date Issued �__a � <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 Ordinaa�nce�No. 549, <br /> JOB ADDRESS AND <br /> LOCATION ---- ----- _ � - <br /> Owner's Name. �// ------- --------------- ---------------------------- P on <br /> AddressLl• = c -_ --- ----- -- ----- ------------------------------------------------------------QQ--------q-•--•--------.._..---- <br /> Contractor's Name -•------`- ------------ ------------------------------- ------------------------------------------- Phone---1----f__�A--�T------- <br /> Installation will serve: Residence ❑ Apartment House eCommercial ❑ Trailer Court ❑ Motel ❑ Other <br /> � i <br /> Number of living units: __ Number of bedrooms ___�l- Number of baths --- Lot size __/_dO'____1C ' ' --�_______________ <br /> Water Supply: Public system Community system ❑ Private [Depth to Water Tables_ _ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay ❑ Adobe 2/"Hardpan ❑ <br /> Previous Application Made: Yes [] No 2-' New Constr tionn: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS- <br /> (No septic tank or cesspool permitted if public sewer is laivaila6le within 200 feet. <br /> r nn <br /> Septic nk: Distance from nearest well _.a4____Di0j , %f� n1�fg)jnda i n___f¢______-__.Materi4� C,' <br /> ''T� <br /> No. of compartments__.__ . _ '.._Siz _ ,+_ __'_ _{}_.___ iqu'rd depth___f ______________Capacity_�d_�B._/__ <br /> Disposal ieid: Distance from nearest well.��f_d.___.__Distance from foundation____�r-.Q__.-___Distance to nearest lot line___.___-_ <br /> Number o: lines___.--____ .-y-46p Length of each line__�0---- -1_�_____-Width of trench_.. _f/�� <br /> r - __________________ <br /> Type or filter material------ _______________Depth of filter material____-/ __________._Total length-_._�_.Q ____-___________________ <br /> r � <br /> Seepage Pit: Distance to nearest well__tQd___..___Distance from fou ation__-_ 0•._.___.Distance to nearest lot line_____3_____ <br /> Number of pits-------.----------Lining material_l�- - ------------Size: Diameter------ Deptn_--��----------------------- <br /> Cesspool: Distance from nearest well_________________Distance from foundation---.----------------Lining material-------------------_________________L <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity_--------------------------galss <br /> Privy: Distance from nearest well----------------------- .---------------------_Distance from nearest building------------------- -------- ----. <br /> ❑ Distance to nearest lot line------------------------- ----------------------•---•----------------------------------------------------•------------- <br /> Remodeling and/or repairing (describe)-------- ----------------------------------•---------------------•------------------------------------------------------------- -•-------------- <br /> - ---------•--------------------------------------------------------------------------------------------•--•---------------------------------------------------------------- ------------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> ordinances, State I�v�s� and rules and regulations of the San Joaquin Local Health District. <br /> ��fv/ <br /> t <br /> (Signed) �'� -- ----------------------------- Owner and/or Contractor) <br /> BY: - --------- (Title) <br /> (Plot plan, showing si of lot, location o ystem in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------------------------------------- ------------- <br /> ---------•-•----------- DATE---------------` <br /> --- ------ <br /> REVIEWED BY -------- ---- ---------------------------- -------- DATE---- <br /> BUILDING PERMIT ISSUED--------------_-- ---------•--------------- ---- --------------•-------------------- DATE <br /> Alterations and/or recommendations:---------------------------- -•------------------------•----•-•------------•--------- <br /> =---._s$--------- -------------•-•--•--------------------------------------------------------------------------------------------------------------------------------.-------------------------- <br /> ---------- --------------------------------------------------•-•---------- --------------------...... . <br /> . <br /> --- --------------------------- il----•-------•-----------------------•-------------------------------------------------•--•--------------------- --------------------•-----------------------------•---•--- <br /> ---------------------------------------------=-- --- --------------------------••-•-•--•-----•---------------------------•- •----- -----------------------------------------•----------------------- <br /> FINAL INSPECTION BY: __ _ ._' ___ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi.. California Manteca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 <br />