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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <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 described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOBADDRESS AND LOCATION----------------7 "--4----- i----- - --------------------------------------- --------------------------------------- <br /> Owner's Name---------------------------A-. -`-----------­--- -------------------------------- ---------- Phone-------------- -------------------- <br /> Address...----•-••--------------------- ------------------------------------------------------------------------------------------------------------------------ ---------- ----------------- ------ <br /> Contractor's Name.---- 0. �^ ' * �- U( �--�' ��-------------------- --------------------•---•---------------------------- Phone------- -/-- 17-f--- <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 /> Water Supply: Public system 0 Community system ❑ Private f-I Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> 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.) ` -of <br /> Se tic Tank: Distance from nearest well_ --.--_Distance from foundation_---/4-r.._.-..Mater�al_d- ------------ -- ------------ ------------ <br /> No. of compartments---------------------Size---'_ K-_X4-----Liquid depth--------4-O..-....--Capacity------Z �------ <br /> - e { <br /> Dis s Field: Distance from nearest well._.- -=--___ Disfance from foundation------ Distance to nearest lot line_-_--i—�..-.-- i <br /> Number of lines--------------7•---------------Length of each line-------- ----.-------.Width of trench.-------------�4----.-----_.. <br /> p <br /> Type of filter material- ° _Depth of filter material---------IV___-----_Total length._---------------94_'¢'.___----- <br /> Seepage Pit: Distance to nearest well --.------Distance from foundation------------------- Distance to nearest lot line----------------- <br /> ElNumber of pits----------------------Lining material--------------.-_-----.Size: Diameter------------------------Depth------------------------.-------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation __ - j_--------.Lining material-------------------------------------- <br /> ❑ Size: Diameter--------------------------------------Depth----•-----------------------•-------------------_Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well------------------------------------------------- from nearest building------------------------------------------ <br /> ElDistance to nearest lot line---------- -------------------------------------------------------------------------------------------------------------- •---------- <br /> Remodeling and/or repairing (describe):_............................... <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 /> (Signed) -------------------------------------------------(Owner and/or Contractor) <br /> / -----------------------(Title)---------------------------------------------------------------- <br /> (Plot plan, howing 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-------------------------------------2------------------- <br /> REVIEWED BY- - ----------------- DATE <br /> BUILDINGPERMIT ISSUED----------•----------------- -- -- DATE------ -------------------- ------------------ - <br /> Iters io s and/,or recommen ations:...-.:_-. -- _-_._-_---- <br /> 1 ��z '�. w -- -- ----------- --- <br /> ------------- .- . <br /> ---------- -- ------- <br /> _-.4- <br /> I t <br /> --------------------- -------------•------------------------------------------------- ------------------------------------------------------------ --------------------------------------------------------------------------- <br /> FINAL INSPECTION BY--------- • - ------------------------------------ Date--- 1. . . - -- .1�i1------------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street t <br /> Stockfon, California Lodi, California Manteca, California Tracy, California t <br /> ES-9-2M I0-52 Revised W-2100 f <br />