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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. 54(9. <br /> JOB ADDRESS AND LOCATION_ ------------------------------- -------------------------------•------------- <br /> A <br /> Owner's Name------ J o -- <br /> - IV-tj-- _ ir------- 1� - ---------I TY ''? ----------------- ----- Phone. <br /> rr ------------------------------------------------•---------------- <br /> Contractor's Name---------------- I' ----- -----------------------------•-------------------------------------------------------- Phone---- l ------ <br /> Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___I s ___'__ Number of baths .-_--__ Lot size ------ ------------k----'7- - ..---------------- <br /> ___ Number of bedroom - <br /> Water Supply: Public system X Community system '❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam El Clay Loam E] Clay E] Adobe <br /> Hardpan E-1 <br /> Previous Application Made: Yes ❑ No;K New Construction: Yes ❑ NOX <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well____'_ -n----Distance from foundation------to......Material _____-~ _C�L./�Q�Q- --------. <br /> No. of compartments__.___�r___._-. --__Size____+ -x_tC_ _ r._..Liquid depth__-_____+/_�.._______--Capacity____�A / 1` <br /> Disposal Field: Distance from nearest well____-------Distance from foundation-------4F_ ___-_-Distance to nearest lot line...._________ <br /> Number of lines`----------._J----------- __Length of each line_________ <br /> -------Width of trench------?"4—'---------------- 1 <br /> Type of filter materiall%.�9'60A a-Depth of filter materiaL________le_____-Total length-----------2s ____________________ <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 /> 1­1 Size: Diameter--•-----------------------------------Depth------------------------------------=---------------Liquid Capacity-----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_-___.___________-_________________-----. <br /> ❑ Distance to nearest lot line---------------------------------------------------------------------- --------------------------•------------------------------------- --- ' <br /> Remodeling and/or repairing (describe):------------------- + -------- <br /> ------------------------------------------------------------------------ --------------------------------- .-- <br /> ----------- <br /> ---------------- --•-----'--------•---- ---------------------------------------------------------------------------------• ---------------------------------------- <br /> ----•--------------•-•-------------------•-------•------------------------------------------------------------------- -------•---------------------------------------- <br /> 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 /> ___________ -_-_(Owner and/or Contractor] <br /> (Signed) ----------------------------------- <br /> BY= r ------- ----------------------------------------------- (Ti+lei- - <br /> (Plot plan, shcwin size of lot, location f system in relation to wells, buildings, etc., can be placed on reverse side). <br /> i FOR DEPARTMENT USE ONLY <br /> 'f <br /> APPLICATION ACCEPTED BY-----------------------�J-- - ----.---------------------------------------- DATE------ <br /> __ DATE------ ---�-�--- <br /> REVIEWED BY---------------- - --------------- --------- ----Kh, <br /> --------- ---- - - <br /> ------------------------------- <br /> BUILDINGPERMIT ISSUED-------------f----------------------------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------- ------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:-------W V- -------------------------- Date-.--/ ........ ------------------------------------ <br /> SAN"JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South Ameritan Street a 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 <br /> -d <br />