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APPLICATION FOR SANITATION PERMIT Permit No,5- <br /> 1 ! ..--�� ?� (Complete in Duplicate) $. Date issued _ <br /> App ation 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 LO ,AT ------ ��` ------------------------------------ <br /> Owner's Name : r ----------------------------------- Phone., .__ "' <br /> tom- <br /> ---------------------------•--------•----------------- <br /> Addres --- <br /> c <br /> Contractor's Name �� _ --------- Phone �� J <br /> Installation will serve: Residence Apartment House F] Commercial E] Trailer Court ❑ Motel E] Other ElNumber of living units: _ umber of bedrooms _'2 Number of baths ---f_" Loi' size ------•-------------- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table-Z_'-,r_,ft• <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobek Hardpan ❑ <br /> Previous Application Made: Yes ❑ No U� New Construction: Ye-sx No ❑ <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, Distance from foundation---9_f________.Material---_ ...... <br /> No. of compartments--_—,-- ------------Size-.!1,--�� IV--Eiquid depth-�� 3--- ---Capacity--07�2<:�5------ <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line___-____-________ s� <br /> ❑ Number of lines-----------------------------------Length of each line---.--------------------.-----Width of trench----------------------------------- �! <br /> Type of filter material_________________ ___•_Depth of filter material____-_---------_/ ----Total length___________-__-____________-_--- �r <br /> Seepa e Pit: Distance to nearest well;-Distance f �m fo dation_fh----------.Di`ante to nearest lot line--; <br /> Number of pits------/________�ining material, "-� ---Size: Diameter___ _ _ ________Depth_-.-__ _______. <br /> - <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 /> Remodeling and/or repairing (describe):------------- / -----------------------------------------------•--------•-------------------------•-•----•------------------- �'oo <br /> ---•--•------------------------------------------------------------------------------------------------------------------------------------------•-------- -------------------------------•--- <br /> ---------------------------------------------------------------I-------------------------------------------------------------------------..--------------------------------------------• --------------- --------- <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, Stat s, and ru es and regulations of the San Joaquin Local Health District. <br /> -- -----------------------------------------(Owner and/or ontractor) <br /> (Signed --------------------- <br /> Titler - <br /> . } -----•------------•------------------------------•---------_•---------- – <br /> (Plot plan, showing kize 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 TA. <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------ ,l---------------------------------••----------- <br /> Alterations and/or recommendations:-------------- ------------------------------------•-"------------------------------------------------------------------------------------------------------- <br /> ------------- <br /> ------------------------- ------------------------------------------- ........ ------------------------------------ •---------- ------------------------------------------------------------ <br /> If y <br /> FINAL INSPECTION BY---------------------- - =ttoDate ` <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 <br /> ES-9-2M 10-52 Revised W-2100 <br />