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APPLICATION FOR SANITATION PERMIT Permit No, - �-=5---- <br /> (Complete in Duplicate) Date Issued - <br /> . i1 <br /> Applica+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 No. 549.. <br /> ------ ---•------------ <br /> JOB ADDRESS AND C ION ----- ------ ----- J� � ------------- y <br /> Owner's Name_ ---- ---•------ - ------- ---- -----------•--------------- <br /> Phone--------------- <br /> Address �-•-- c�°" }---------1;----- ----- ------------------------ <br /> Contractor's Name--`------------ =--- -- - -- ------------------------------ -------•------=------------ Phone <br /> -• - � ---- -------------- - <br /> Installation will serve: Residence Apart nt House ❑ Commercial ❑ Trailer 'Court ❑ Motel ❑ Other ❑ <br /> Number of living`units: _-�____ Number of bedrooms ._-�: I�Iumber of baths ___ Lot size ----��A-X-10-4------------------------- <br /> Water Supply: Public system 0 Community system ❑ PrivateW Depth to Water Table _2--- ft. <br /> Character of soil to a depth':of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay-L`oam ❑ Clay ❑ Adobe:] Hgrdpan E <br /> Previous Application Made: Yes ❑ Noy New Construction: Yes j No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available i in 200 feet.) A <br /> Septic k: Distance from nearest well___ _-Distance from foundation___-. i___r.___.Material___________________________----________________- <br /> Z_1 No. of compartments------- ---------------.--Size---­---------------------------Liquid-dep.fh---------------------- <br /> ----------- -----Size------•-------------------------Liquid-depth-------------------------Capacity------------ ---- - <br /> ,�r_?.___i.___.Distance to nearest lot line-_--�- <br /> Dispo al Field. Distance from nearest well- Distance from foundation:_ _ <br /> Number of lines---------I-----------------------Length of each ---:-------------Width of trench----"'�"'---------------------- <br /> : Type os -filter material________ � Total length________-__�_:. <br /> ^^� Depth of filter material --- ------------- <br /> M.ksa e i ; Distance to nearest well_______________ <br /> Distance from foundation_____-_--___`____.Distance to nearest lot line________________ <br /> Number!of pits----------------------Lining material-----------------------Size: Diameter------------ ------- Depth'.------------------------. <br /> esspool: Distance from nearest well----------------.Distance from foundation-----_..............Lining material----------________-._--__.____.______- <br /> _; Depth_--: -7 -- <br /> -T------ <br /> L'G -Aga <br /> Privy: Distance from nearest well---------------------------------------------- Distance from nearest building----------------- -------•-------------- <br /> Distance to nearest lot line------- ------ ------------- •----------"-------- <br /> El <br /> . f• <br /> 1 <br /> Res�odeling and/ar repairing�(descr-sbe): __ 1 --- -s- �----- e = a <br /> ' --- ------------ .' <br /> 4� <br /> ~ <br /> ---------------- ----------------------------- <br /> ---- <br /> f -' <br /> ----- - - - ----------------------------------- - ------'-----------------------------------------------------------------= Or <br /> ! hereby certify.that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Sta a laws, and rules and regulations of the SanJoaquinLocal Health District. <br /> -F-___.____ ------------Owner and/or Contractor) <br /> (Signed)------ , Q_. ------- <br /> By--------------------------------------------------------------- ------------------------ (Title]--- --------- <br /> ---------------------------- <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----- ------- --`---- DATE--•--------•------- <br /> ----------- ----------------------------------------- <br /> - -------- ---------------- <br /> REVIEWED BY ---------- ------------------------------- DATE ----�---- -----------•------- <br /> ------- -- -- - -- <br /> BUILDING PERMIT ISSUED----- - --- -------------------------------- DATE-------------------------------- ---------------------------- <br /> --------------------1------ <br /> Alterations <br /> ---- •--------------------- <br /> Alterations and/or recommendations------- ------------------ ---------------------------------------•--•------------•------ <br /> = -----------•---•-•----------•--------------------------•--- <br /> --------------------------------------------- <br /> IONBY----------------------------------------------------------------- <br /> SAN <br /> ---------• ----- <br /> ----------------------- <br /> FINAL INSPECT - -- --- ----------- Date- ------------- ------- - - <br /> --------- ' <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 1 <br /> ES-9-2M Revised W-2100 <br />