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APPLICATION FOR SANITATION PERMIT Permit No. ._._ �_ � <br /> (Complete in Duplicate) <br /> 4 <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health Disfrict for a permit to construct and install the work herein described. <br /> This application is made in compliance with ounty Ordinance o. 549. <br /> JOB ADDRESS AND LOCATION-------------- <br /> ______ ___ __ _ _ <br /> - -----------=---------- ------ --- -— ----------------------t----- ----------------------- <br /> Owner's Name ___ ------- ----- ---------- Phone-------------------- <br /> Address-....... ---------- ------------ ----------- <br /> Contractor's <br /> ---------Contractor's Name----- ( -_ - — _ _-_ � -- --- <br /> ---------------------- ---------------------Phone <br /> 3 Installation will serve: Residence 'i� Apartment House ❑ C rpme tial ❑ Trailer Court ❑ Motel ❑ Ot er 0 f <br /> ' Number of livingunits: __�__, Number of bedrooms __l_____ umber of baths __ ""'_'---- <br /> - <br /> Lot size _:_JJ_ _X/ �----- s <br /> Water Supply: stem LTJ Public system t Community stem ❑ Private ❑ Dep <br /> :i +th to Water Table �U_ ft. <br /> , Y sY � <br /> Character of soil to a depth of 3 feet: Sand ❑ .Gravel;❑=;Sandy Loam [.]� Clay Loam ❑ Clay.❑ -Adobe [j Hardpan ❑ <br /> Previous Application Made: Yes El No E] New Construction: Yes LZ No ❑ FHA/VA: Yes [7] No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: _ V <br /> No septic tank or'cess ool!permitted if public sewer isiavailable within 200 feet. <br /> Septic, Tank., Distance frominearest well__ti"L ___ Distant fr m fo ndation'____ -1�___--_Mat pial-----------------�/�- �- <br /> p <br /> © No. of compartments__._� --------Size_ ._x,_,rf� Liquid depth____________.____Capacity___ !._ _' •__ --- <br /> Seepage <br /> Disposal Field: Distance from[nearest weli__� ____.Distance from foundation__-_ _____.__Distance to nearest lot line_ :_____..___ <br /> Q a • Number of lines---._________________ _.__ Length.of each line_________ .j� Width of trench.;_- --------- <br /> of. filter material-___ [Depth of filter material -----------Total length=_______ _______________________ <br /> Seepage Pit: Distance-to,e rest well----------------------Distinc'e 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---------------------------------------Dep th---------------------------------- ter; Liquid Capacity----------------------------gal <br /> Privy:' ^* ""` . Y Disfance_from;-nearest well ._' ' ___ _________ _ <br /> Y ❑ ------------ -istance from nearest building---------------------------------------,-. <br /> Distanceto-nearest lot line--------------------- ------------------------- --------------•----------------------------------------------------------------------------- <br /> Remodelingtand/oi repairing (describe) --------------------------------------`_..�- -----4--------------------------------------------------------------------------------------------------- <br /> ----------------------------=-------------------------------------------------------------------------------------•-------------------------------------•--------------------------------------------------------------------- <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 regulations of the San Joaquin Local Health District. <br /> • f <br /> _ <br /> (Signed)- / ---------- -------- --------------------------•-------------- --------- ----------------------------------------(Owner€and/or Contractor) <br /> t <br /> By:------- ----- --------- - - ---------------------------------- =------F-------------------------(Title)-------------------------------------------------------------- <br /> (Plot plan, wing size of lot, location of system in relation to wells,' buildings, etc., can be placed on reverse side). <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- DATE 6111:4--1 <br /> REVIEWED BY----------------------------------- t DATE <br /> - :V <br /> ---------------------- �---------------- <br /> BUILDING PERMIT ISSUED------------------------------------ ---------------------------------------------------------------- DATE----------------------------------------------------- <br /> Alterat'ons and/or recommendations:-------- --------- ------- ------------------- ---------=----------------------•----------- --------=---•-•---------------•------------ <br /> ---.... - - - - -- -- --------- <br /> ... <br /> - --.- __:_ ( <br /> ------------------------- --- `- ------ ;-; ; '------ -- - =-----:y <br /> ----------------------- <br /> FINAL INSPECTION BY: "--------------------------------------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ff <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 1.57 F.RCO- <br />