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APPLICATION FOR SANITATION PERMIT Permit No.s1 �-- Z' <br /> in Duplicate)(Completep I Date Issued <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.Q - n <br /> JOB ADDRESS AND LOCATION B -�- -- -`- "` ti` a' " ---------------- <br /> Owner's Name _s�"_G'_4-_ Phone <br /> ,,, ----J-------------- <br /> Address----------•------------------�---�--------- ----------------------------- 4 <br /> Contractor's Name---------.<__-+(� t� l 7 P--- L--27---�U_�.rl_ �� Phone. = �/ <br /> Installation will serve: Residence <br /> House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units- J-__ Number of bedrobms,3___'Number of baths _/-____ Lot size ----------- ._------_________________ <br /> Water Supply: Public system ❑ Community system ❑ Private Z;--Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay M-Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ED New Construction: Yes E3/16o ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Se tic Tank: Distance from nearest well, -----Distance from foundation__-_/ _______Material__4_ _______. <br /> p No. of compartments----------- depth--------- ___�a r' Capacity.... <br /> Disposal Field: Distance from nearest well Z7_..._Distance from foundation___�Q----------Distance to nearest lot line______S___. <br /> Number of lines---------------y_--- Length of each line_----�Q__-----------Width of trench-------- �11-______________ <br /> Type of filter materia____ ____ . 4i'�Depth of filter material___--- .. .........Total length_________________l ____________ <br /> Seepage Pit: Distance to nearest well___---------------------Distance from foundation....................Distance to nearest Of line----------------- <br /> El Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material___-_________________.________-__ <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity- ----•-------------------gals. <br /> Privy: Distance from nearest well. _____________________________________Distance from nearest building_______.____-___----.-.__.____._________- <br /> ❑ Distance to nearest lot line -------- ------------------------------------------------------------------------------------------------------------------------------------ <br /> Remodelingand/or repairing {describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------- <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 rule's a d regulations of the San Joaquin Local Health District. <br /> d[Signe - ----- -- ..._ �___ .'�'',�-� ----- - --- �----------------------•------------- - ---------------------------------- -(Owner and/or Contractor) <br /> By:-----___-----------------------------------------------------------------------------------------------•------------------ -----(Title)-------------------------------------------------------------- <br /> (Plot plan, shkwing 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.----- E v <br /> REVIEWEDBY------------------------------------------------- -------- -----..._ DATE.- ------ - --- ---- --- <br /> BUILDINGPERMIT ISSUED------------- •-------------------------------------------------------------------------------------- DATE ------------- -•-------------------- <br /> Alterationsand/or recommendations------------ -------------------------------------------------------•-------------------=--=--------•----------•-------------•--------------•------------------- <br /> -------------------•--------------• -•---------•------------------•-------------------------------------------------------------------------------------------------------------••--•-----------------------------------._.. <br /> ---------------------------------I---------------•------------------------------------------------------------•------------------------------------...------------------------------.----------------------------------- <br /> ------------­------------------------------------------------------------------------------ ------------------•----•---------- -----------------•-----------------------•--•-------•-------- --•----•--=•------------------- <br /> FINAL INSPECTION BY: ___________________________.- - <br /> ---- ------------•------- Date----------- 7777�---------= ------------------------- <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 Revised W-2100 <br />