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--------------- - = --------------- ------- ----------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. .../ . ..... <br /> --------------------------------------------------------- (Complete in Duplicate) <br /> Date Issued __. / <br /> ----------------------------------------------------- --- This Permit Expires 1 Year From Date Issued <br /> 3/v. <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 /> JOB ADDRESS AND OCATION._ 14 J.. .. -------------------------- -------------r�.....'R:...-------- <br /> Owner's Name ............................................. Phone............................f! <br /> AddressQ R. 2 .--� S C? ------- <br /> Contractor's Name--------- ---------------------------------•----------------------------------- Phone...................----•----•--_.._ <br /> Installation will serve: Residence � Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: j..... Number of bedrooms ,__'. Number of baths ---/-- Lot size ....k9__X- 3e,............................ <br /> Water Supply: Public system ❑ Community system Private ❑ . Depth to Water Table <br /> Character of soil to a depth of 3 feet: Sand X Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adoldilelp Hardpan <br /> Previous Application Made: (If yes,date -: <br /> No J Nerd Construction: Yes No ❑ FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICA►TIO M5: <br /> (No septic tank or cesspool permitted if, public se er is available within 200 feet.) <br /> Septic, Tank: Distance from nearest well tan a from foundation-_10_--------.Mate iat___.. <br /> No. of compartments..-_: ___. .__._Size._ X�_Q__k__;a..___Liquid depth______..'7"_ �"Y_Capacity_..!�itg. -- -- <br /> Disposal Field: Distance from nearest well tance from found *on �D___..._.Distance to nearest lot line . <br /> Number of lines........ ------­------- Length of each line_ .____/a..yf._.Width of trench //// (� <br /> 7` --- <br /> Type of filter material__ ___ _ �___Depth of filter material_._,'�.,_ ___....Total length..... ............................. <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...................................... <br /> ❑ Size: Diameter--------------------------------------Depth------.--------------------------------•------------Liquid Capacity----- •-----•--•--.gals. <br /> Privy: Distance from nearest well____________________------------------------------Distance from nearest building_----------------- <br /> ❑ Distance to nearest lot li <br /> Remodeling and/or reayrin describe:-- ----------- ---- -- ------- -------• -- ---- <br /> ------------------------- - -------------------------- -------------------------------•-------------------------------•-----------------------------------------••-----------------------------------. V. <br /> --- ......•------------------------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 0 <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local HealfR District. <br /> (Signed)... l i` t— ----------------------------------- ------ -------------------------------------------------------------(Owner and/or Contractor) <br /> By:--- ----------------------------------------------------- ------- -------- •---(Title) <br /> (Plot plan, showing sizf 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 /> REVIEWED BY---------------------------------------------------------- -- _ DATE...... ... C7 <br /> BUILDING PERMIT ISSUED...................................... --- :;� <br /> ----•-•-••••.-----•-•-•-. DATE.---•-•-•-----•---•--- ------------�- <br /> Alterations and/or recommendations----------------------------------------------------•-•--------------•--------------------------•-•---------------------- -- <br /> -•---------------------------------------------------------------------------------•------•---------------------------------------------------•-•-- <br /> ------------------------------------------------------------------------------------------------- •-----------------•-----•--------------------••---•--•-------••---•-------------•-------••-----•--•••-----•-----••---------- <br /> fir / <br /> FINAL INSPECTION BY:.-------- ----- Date---------------. -~ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Strout 300 West Oak S?reot 124 Sycamore Street 205 Wart 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES-9 REVISED B•59 F.P.CD.2M 6.60 <br /> h <br />