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{(K APPLICATION FOR SANITATION PERMIT Permit No.,q-_-/_ <br /> (Complete in Duplicate) <br /> oph . Date Issued �� .-�' `r <br /> Applicaa-ion is hereby made to the San Joaquin Local Health District for a permit t onstruct nd install the work herein described. i <br /> This application is made in compliance with County Ordinance 549. <br /> JOB ADDRESS AND TION------- .. <br /> ------------------------------------C------------- <br /> Owner's Name -----------------• ------ --- -------- Phone--,--`- x^ <br /> J <br /> Address_ -,.---------_ ----- <br /> = <br /> Contractor's Name -- <br /> -------------------------- -----------------------•----------------------- Phone-, -.=,�Fr� <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 <br /> - ----------------•-- <br /> Water Supply: Public systern�<Community system ❑� Private ❑ Depth to Water Table�Qft. n <br /> Character of soil to a depth of 3 feet: Sand [IGr`el ❑ /Sandy Loam ❑ Clay Loam•❑" Clay ❑ Ado11(KHardpan ❑ <br /> Previous Application Made: Yes ❑ NoNew Construction: Ye No IF.-) I <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septiclank: Distance from nearest well-----------------Distance from foundation-------------------Material <br /> _-------_-------.--__---------.-_-----___-_--. <br /> I <br /> r No, of compartments ------------Size-------------------------------Liquid depth------------------------- CepacitY <br /> Disp sa} F' Id: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line------_-----_--- <br /> , ' Number of lines-----------------------------------Length of each line----------------_------------Width of trench <br /> Type of filter material-_----------------------Depth of filter material----.-.--.--_-------.-_Total length--------------- <br /> Seepa� e Pit: Distance to nearest well_ ------Distance fr m fou ation,,0'.-!_-'.Distance to nearest lot line- <br /> Numbe <br /> r of pits.---/---------------Lining material- ...-_ - .--.Size: Diameter-__V---_-_-._.---__Depth---npCesspool• —Distance from nearest well----------------Distance from foundation-__.____--------.'Lining material-------_--------____--❑. Size: Diameter----- ---------------------------- Depth----------------------------------------------- ----Liquid Capacity----------------------Privy: ; Distance from nearest well-------------------__-____---.-.---------------Distance from nearest building--_----_-._-_-----------_._Distance to nearest lot line__--.. i----- �------ ------ ---------------------------------------------------i Remodel•ng;Td-o repairing (describe):--- j i -- <br /> . -------------------------------------------------- <br /> ---- ------------------'-- ------- -------------'-----'------ - ----...- - ---- -------•-----------•--- ----------------------------------- <br /> ---------------------_-_-----_ <br /> -------------------------- ---------- -- <br /> ---- -__------_-------------_-- k_ __ ------------------------- <br /> -- <br /> -----------------------------------__-- <br /> I herebycertifythat I have prepared this application and that the work will be done i - ----._--_ -- <br /> - <br /> n accordance with San Joaquin County s <br /> ordinances, Sta laws, ndoerules and recfula+ions of the San Joaquin Local Health District. <br /> 00 0;4K <br /> (Signed)----- <br /> --ra <br /> - -�-------�-r --Owner an / ) <br /> B . or Infractor] <br /> os <br /> Y - ---------------------------------------- ------ ---(TitleL�, <br /> "-�--------...-,�':-eJf -(Plot plan, showing si , location of system in relation to wells, buildings, etc., can be onreverse s�). <br /> ' FOR DEPORTMENT USE ONLY <br /> APPLICATION ACCEPTED.BY-�- ----- __ -------------------------•- ------------------------------- DATE <br /> ----{------------- ----------------------- <br /> REVIEWED BY - --------. DATE .------- - <br /> BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------- DATE---- <br /> Alterations and/ or recammendations:-----_-----------------------_ .­- ---,. — - t------------------- i <br /> i <br /> ' = - i <br /> -------------------------------------------------------------- <br /> ------------------------------------------------------- <br /> ---••------------------------------------------ e <br /> FINAL INSPECTION BY:-._ ------ Date... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C' Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ; Revised W-2100 <br />