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APPLICATION FOR SANITATION PERMIT Permit No. .---h�..-_. <br /> (Complete in Duplicate) <br /> -- --= - riDate Issued <br /> App ication 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 incompliance with County Ordinance No. 9. <br /> JOB ADDRESS D,LOCAT1bN `� --------- <br /> Owner s Name-- °- Phone___ <br /> -•--------- <br /> Address •- ----------- --------------------------------------------------------------------------------------------- <br /> Contractor's Name----------------------------------------------------------------------------------------------------------------------------- ------ Phone--------------------- <br /> Installation will serve: Re idence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ MOAPI ❑ Other <br /> A•Number of living',units: __- Number of'bedrooms Tr7:�-- Number o baths -------- Lot size ----- ------------ ----.---- '--'__-----------_-- <br /> Water Supply: Public system E] Community system E] Pr epth to Water Table -------- ft. <br /> Character of soil to a depfh'of 3 feet: Sand E] Gravel Sandy loam Clay Loam E] Clay [3 Adobe Hardpan ❑ �j <br /> Previous Application Made: Yes E] No Rr New Construction: Yes ;No ❑ rl� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or-cesspool permitted if public sewer is available within.200feet.)) <br /> Septic Tank: Distance tfrom nearest well----_._----____Distance from fou --------------�- -. <br /> r"dation _ Material-------------------------------_---_--------_-. <br /> ❑ No. of�onipartments-- ---------------------Size--------•-------------3 .-!,Liquid depth--------------------------Capacity------ ---------------- <br /> Disposal Field: Distanc5jin nearest well---__.._-.___.-Distance from foundation'--i-----_-.-�----Distance to nearest lot line--------------_ <br /> ❑ Number of Iines-----------------------------------Length of each Iih e--------------'` ------ ----Width of trench-.--------------------------------- <br /> Type of filter material-------------------------Depth of filter material--------.------- Total length--____-__._._----.----------------_----. <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation------------- Distance to nearest lot line--.----.------__ <br /> Number of its . z'-_—__,l ini' "Fn'aterial----_-_.-__---- ---.Size: Diameter'­--�..............Depth _-__.17.-------------.--�- <br /> ❑ p" f <br /> Cess po Distan xf om 1 est Il _-.----- istance from fo gclation!-.I�.l Lining material_- ------- <br /> Si _ --- -.- <br /> ze: Diameter 'bepth Liquid Capacity 44` <br /> gals. <br /> Privy: Distanele from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- <br /> Distance <br /> -----.--.-_-.------_----_---------____-Distance to nearest'It line------------------------------------------------------- ------------------------ --------------- --------- -------------------------- <br /> emp®eling and/or repji_iring [de;eribe)A--- --- ---- ----------------- 3 .. -- <br /> II �- <br /> ----------------------------------------------------------------------------------------------------.........--.--------------------------------- <br /> I - <br /> ---------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------- <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, St s, and It:ui s and regulation`s of the San Joaquin Local Health District. <br /> (Signe d........ ---------------------------------------------------------------------------------------{Owner and/or Contractor) <br /> B1 -----------------------------------------(Title)------------------- ----------------•--------------------------- <br /> i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> t <br /> li FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------- ----------------- --------------------- DATE <br /> REVIEWED BY----------------- 1)- ----- __. --------------------------- ------- DATE- <br /> BUILDINGPERMIT ISSUED--------- �---------------- ------------------- DATE--------(------------------------------------------------ <br /> Alterations and/or recommendations:------------------------- ------------------------------------------------------------------------------------------------------I•------...------------------- <br /> ------------------- <br /> ----------------------------- ------------------------------------------------------------------------------------------------------•-•--.•-------•---•----------.----•--------------------------- <br /> -----------------------------------•--------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------- <br /> ----------- ------------------------ -------• - ----- -----------------------I----------------------------------------------------------------------------------------------------- <br /> 4[ !� <br /> FINAL INSPECTION BY---------------- Vx �. Date - 5-------------------------- --------------------------------- <br /> 11 <br /> -- - -- <br /> Il <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 I0-52 Revised W-2100 <br />