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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) 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. _2 '4-5-0-0 ^0 <br /> JOB ADDRESS ANDLOCAT O 'Tse` ' - <br /> Owner's Name-------- <br /> = R : <br /> ljl � Phone <br /> Address-----------------� --------1) ----��-f--------------------------------------- - - ---- ------------- ------- ------- -------------------- - ----------------•---------------------- <br /> Contractor's Name--------- � � Phone------� 3 <br /> Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ <br /> ' _fit_ ..v" 'I _:, .b...-�----► <br /> Number of living units: __.�_�Number of bedrooms`__ __ Number .of baths _,_----- Lot size __ 1 __ � <br /> Water Supply: Public system ❑ Community system ❑ Private 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 0 <br /> Previous Application Made: Yes ❑ No ©' New Construction: Yes f No .❑ <br /> TYPE OF INSTALLATION AND.SPECIF&TIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest weli___ _ -Distance from foundation____yL_�}______Materialf"__(�f - �c' N' <br /> xr-IfNo. of compartments_____�__ 4$___?:�;--k-""Liquid depth________-".--------___Capacity_ rte_______ <br /> Size <br /> Disposal Field: Distance from nearest well---- 2---.Distance from foundation---- --------Distance to nearest lot 1•ne-y _ ___ <br /> Number of lines_--------- -----------------I.Length of each line_ _( _ __ "`_ _ ".Width of trenchA-0 <br /> _ ___________________ <br /> ` ---Total len th ------------------ - <br /> Type of filter material__,.�� _ I�epth of filter material___,��_--_-_____ g <br /> ,Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line______-_-________ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-----;--------_---------------.-- <br /> Cesspool: Distance from nearest well-------------------Distance from foundation___._______---_.__lining material--------------------------------- I <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity---------------- -------gals. <br /> Privy�. �D tance o nearest4 of line - f ------f--------A ---------- ------------- -- <br /> : Distance from nearest well_____________________________ _______________ __Distance rom nearest 5uildm j'"__ _____________________--__--_______.y <br /> El <br /> f <br /> Remodeling and/or re �iring' <br /> (describe):__ -- ----------------------- <br /> - ---------------- <br /> ------------------------------------------------------------------------ �" � '1 ------ 'P' <br /> -------------------------------------------------------------------------------------------------------------------- ------------------- ------ ------------------------------------------ = <br /> k _________________________________ ________________________________________________________________________________________________________________________________________---_-_-.__._______________-____________-_____-_____ 1 <br /> 4 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 /> � _ �-_ <br /> (Signed) a e----�.� - (Owner and/or Contractor) ; <br /> By:---------------------- --- -- -------------/-------------- --------------------------------------------------------------(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 /> APPLICATIONACCEPTED BY--------------------------------- ---------------------------------------------- DATE_----------------------------------------------------------- <br /> REV,I,EW ED .BY=�__._---_,---�- ..-:;r__:-.:-w--: ---: -- .- ��-� - -- ------- - ------ ----------------------------- DATE------------ --------- ----- --�--•--------------------------I------ <br /> -•------------ <br /> BUILDING PERMIT ISSUED -- ----_ ----------------------------- DATE----- ----- <br /> Alterationsand/or recommendations:-/----------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------•--------------------------------------------------------------------------------------------------------------- ----------------------------------------------------•------------------------------------------------ <br /> r <br /> ------------------------------------------------------------------•------------------1'------------------------------'--------------------------------------------------------------------------------•--------------------- <br /> ----------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------•---- <br /> --------------------------------------- ��-„� ---- -' _----- - ---------------------- <br /> 1 <br /> p ✓C � <br /> FINAL INSPECTION BY: Date <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---2M1 8-51 Revised W-2100 <br />