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APPLICATION FOR SANITATION PERMIT Permit No-yJ Y....... <br /> (Complete in Duplicate) J/ <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 descri ed. <br /> This application is made in compliant with County Ordinance+No. 549. <br /> C -JOB ADDRESS AND LOC N -- ` ------------ .-----v---------�--.� r <br /> --�'--•------•---------- <br /> -- ------------------- <br /> Owner's <br /> Name-------•------------ --------�__-F- - ----- ------- --------- --------- <br /> ----------- Phone <br /> r L <br /> Address---•--• -------------------------------------------------------------- --------- 5'------- -- -------------- <br /> Contractor's Name------------------------- Sr --- --------•---- Phone.------------------------------ <br /> Installation will serve: Residence] (Apartment House [j Commercial [] Trailer Court El Motel E] Other L]Number of living units: -_.[_--- Number of bedrooms __ Number of baths ._' .. Lot size -------------- -_-- .-.�.��_ ---------- <br /> Water Supply: Public system Community system .0 Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel ElSandy Loam [-] Clay Loam ❑ Clay ❑ Adobe �ardpan L]Previous Application Made: Yes ❑ No New Construction: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well----- ---------Distance from foundation--------------------Material.-----__----------------_----...._--__------___.. <br /> ❑ No. of compartments--------------------------Size---------------•----------------Liquid depth--------------------------Capacity--._. <br /> - ----------------- <br /> s i-•/ <br /> Dis osal Field: Distance from nearest we --'_Distance from foundation_ __��.__-..Distance to nearest lotine_- <br /> Number of lines................ _ --- Length of each line------- _�_ -_!_.Width of trench___. ,......__....___.... <br /> vv ------ <br /> Type of filter material_._t...T..-�OiltDe th of filter material- length__-__._3f1_...__�_(���. <br /> YP � )- #�- p � <br /> } <br /> Seepage Pit: Distance to nearesf well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> El Number of pits----------------------Lining material----------------.------Size: Diameter------------------------Depth--_----------------.------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- <br /> 171 Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> FlDistance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):------------------------------------------ --------- ---------------------------------....................--------•---.......... .............. <br /> ------------------------------------------------------------ - - - --`- �---------------"-"Fj�cl__C_ - ---------q- 'd-1- - - -----=------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------- <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinanc�Sfla S, and rules anegulations of the 5a�n aquin Local Health District. <br /> Si ned �- •---- ----------------- Owner and or Contractor( 9 ) { / ) <br /> By:------------------------------------------------------------------------------------------------------------------------------------(Title)------------------------------------------------------ <br /> ---------- <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 /> REVIEWED BY -------------------------------- DATE ---------- � <br /> - - -' <br /> BUILDING.PERMIT ISSUED--------------------------- ---------- --------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations----------- ------------------------- ---------------------------------------------------------------------------------------------------------- <br /> ------- ------- - ----------- <br /> ---- ------�- - - ---- ---------- "--.,---- =------------ - <br /> f ,7. 1 ,-- .a..�_ _�, -------�.�,� <br /> FINAL INSPECTION BY:--------- - e------------------------ Date-------------------, ---------------------------------------------------- <br /> .SAN <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 8-51 Revised W-2100 <br />