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APPLICATION FOR SANITATION PERMIT Permit No. ._-. t) <br /> -�---'------- <br /> (Complete in Duplicate) <br /> Date Issued <br /> t <br /> Applicaa-ion 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 NN <br /> L©GATION <br /> -----k--JOB ADDRESS AND � � �G- �7 <br /> --------------------------------------------------------------------- <br /> Owner's Name----------��.-. ���� ----- ------------------------------- - Phone----•-------••------------------•--- <br /> Address - f, <br /> ----- --------------- <br /> 1 <br /> Contractor's Name------- F-IFr �E" ' 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 _________ _ ___�____ J----------------- <br /> 3 r <br /> Water Supply:' Public'system © Community system ❑ Private ❑ Depth to Water Table �--"_--- ft. <br /> Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 6 Hardpan ❑ <br /> Previous Application Made: Yes J5 No [)d 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__Na--___Distance from f u.0dation.--_-- _--____--_Material--_G-�____ ____J---------.______- j <br /> p No. of compartments__._______________Size__ �_/r _�__-___Liquid depth-_.____��_-.r________Capacity......yiV_______ <br /> r <br /> Disposal Field: Distance from nearest well-:_1VdZ ,.Distance from foundation_______71" ______Distance to nearest lot li�I__.a?�...... <br /> [ Number of;lines--------- ---------- ----Length of each'line------_ ='---------------Width of trench____,5 -V--_-•------------------ 4� <br /> Type of filter material � �___Depth of filter material_.__1 _ <br /> __` ___________Tatal length--,------ '____________ t <br /> Seepage Pit: Distan eo tnearest well._;_1Y4-Z -:Distance from fou dation___ -----------Distance fto nearest lot line____ ---- <br /> �I Number of pits-------/----_- K---Lining materiall(f_ - _I_� e: Diameter____.,`��---------Depth----- --- <br /> ------------------- <br /> Cesspool: <br /> --_f_______________Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- <br /> F1 Size: Diameter------ ------------------- ------ ----Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest'well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> ElDistance to nearest lot line------------"= ----------° ------------------------------`--------------------------------------------------------------- <br /> Remodeling and/or repairing {describe)!------------------------- -------------------------------------------------------•-------------,----------- <br /> ----------------•--------------------------------.-------•---------------------------------------------------------------- <br /> ----------------------------------------------------------------------- -------------------•----------•---•- ..---- ••- ------------- -------------------------------------------------- <br /> --------------------•-- -----•------- <br /> --- <br /> I hereby certify that_! have prepared this application and that the work will be done in accordance with San Joaquin County :1 <br /> ordinances, StaIpWiC an rules and'regulations of the San Joaquin Local Health District. <br /> (Signed) _ --------- Owner and/or Contractor) <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 - ---z-- --------------------------------------•------ D 1 ' <br /> ------------------------------- ----------------- <br /> -BY--------------------------------- -----j- - ---- ------ --------------------------------------------------------------- DAT -- ---- -- <br /> - ----------------------------------------- <br /> q BUILDING PERMIT ISSUED----------------- --- -- ---- -------------------------------------------------- DATE---------- ---------j <br /> and/or recommendations:.i-_________________ 1 . <br /> i ------------- ... <br /> ------------------------------------------------------------- --- ---------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------ <br /> - <br /> ---•---------------- --•---------------------------------------"------------------------ ------------------------------------------------------ ------------------------------------- ------- -------------------------- <br /> -------------•------------------------------------------ -------•------------------------------------------------ -------- ------- ------------------------------ -----------N ----------------------------- <br /> k �o ( / <br /> FINAL INSPECTIO -BY_______ _ ____ Date_.. _'__-y./ \J <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-4--•2M ; Revised W-2100 <br />