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APPLICATION FOR SANITATION PERMIT <br /> Permit No. `3__l <br /> (Complete"in Duplicate) ate Issued :` 1 <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to co tluc stall the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION_'J _ -1- = = ------- k--------• u IC.. �`�_ � <br /> Owners Name " f 11.E r---- Phone <br /> _ .� <br /> Address ----------------------------•--•--------------------------------------'------ <br /> -� '' r _ 1 <br /> Contractor's Name-----`---------------------------------------•---------------------------------------------•-- --------------------------------------------- <br /> Installation <br /> - ----------------- Phone <br /> Installation will serve: Residence (�Apartment House ❑ Commercial ❑ Trailer M1C uet ❑ Motel ❑ Other E] <br /> Number of living units: A---- Number of bedrooms A-___ Number of baths _n__ :Lot size ____I r _�___- -------------------- <br /> �S <br /> Water Supply: -Public system ❑ Community system ❑ Private 210'Depth to Water'Table 6_!r-ft. o- <br /> Character of soil to a depth of 3 feet: ' Sand ❑ Gravel ❑ Sandy Loam lay Loam E❑ Clay ❑ Adobe [] Hardpan ❑ a <br /> Previous Application Made: Yes ❑ No 5�' New Construction: Yl No ❑ <br /> V i <br /> TYPE OF INSTALLATION AND SPECIFICATIONS <br /> (No septic tank;or.cesspool permitted-if public�sew�is available within 2fl0 feet.) - ' <br /> _ . ... <br /> Septic Tank: Distance from nearest well____1? ____,Distance f om f, ndation_ .y _ Material___ d _ ___ _____ _Q _`* <br /> l t, <br /> No. of compartments------._�...---=--- - - Size Liquid depth -- --- Capacity.- ' <br /> Disposal ield:w- -Distance-from nearest well_=,4-0-- Distance from foundation_y-'_ Distance to nearest lot lire.-,�-t______- <br /> Number of lines------ __t,_--_____i4-_____.__Length of each line- _-____1- !--.-.Width of trench_._---"- <br /> Type or filter material-� �._, ��_1R4epth of filter material_._.__�_�.-_______Total length___________ __ _______________________ ,f <br /> Seepage Pit: Distance to nearest well_____________._____Qistance from foundation____________--------Distance to nearest lot line____________-_-- <br /> �❑ Number of pits-__.--- -.----Lining material-----------------------Size; Diameter---------------------- Depth-------------------_------------- <br /> Cesspool: Distance from nearest well-----------------_Distance from foundation--------------------Lining material-------------------- .--___________. <br /> Size: Diameter-----=- ------------------- Depth_-------------------------------------------- ------Liquid_Capacit.Y— w gals._ <br /> Privy: Distance from nearest well ------------------- ---------------------Distance from nearest building_____.-______________________--_-___-_. <br /> ❑ Distance to nearest lot line-------------------------------------------------:----------------------------------------------------------------------------------------------- <br /> --- --------------- --------------------- --------•----....-•------------------------------..._... <br /> Remodeling and/or repairing (describe:--_________________________._____________-.._.______ •• <br /> f <br /> l _____________________________________________F..------------------._-.________-_-._._______....-_..___.------.-_________.__----___________________________.._..._.____________.-____________-___._ <br /> T . <br /> I hereby certify that I have prepared this application and that the work will.be done in accordance with San Joaquin County <br /> y <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) <br /> x �ll ---------------------- __Owner and/or Contractor <br /> - ----------------------- <br /> i BY=----------------------------------- ----------------------------------- :::--------- ------------'---:--------------------(Title)-------------------------------- - = = - -_---=---:__ Y <br /> _ r- -- <br /> (Plot plan,showing size of.lof, location of system in relation to wells, buildings, etc., can be placed on reverse side]. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY---- --- ---- -----------------­­--------- ------------------------•--------------------- DATE--------�-- ------- -- •--------�- -•• ------------ <br /> REVIEWED BY ---------- - DATE - <br /> BUILDINGPERMIT ISSUED--------------------------------------------•---------------•---------•-----------------------------• DATE----------- ---•------------------------------------•-------- <br /> Alterafionsand/or recommendations------------------- -------------==---------- ------------------------ ---------••------------...--------------------•-----------------------------------•--- <br /> -------------------------•---------------------•------------------------------------------------'----------------- -----------•-----------..-----------•----••----•-•---------------•--._.....---- <br /> _______________________ __________________ ____---------------------------- <br /> _---------------- <br /> --------------------____________________ ___ ________________________________ _ _______ ____ <br /> FINAL INSPECTION Dat <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 /> k <br /> ES--9-2M Revised W-2100 <br />