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l� / <br /> 1 APPLICATION FOR SANITATION PERMIT Permit No. �7//_��,1--.... <br /> (Complete in Duplicate) G <br /> Date Issued <br /> A,plica+=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 rdinance No. 549. <br /> JOB ADDRESS AN LOCATION--- -�--- - � -------------------------------------------------------------------------------------- <br /> r9-�i� <br /> Owner's Name �'f�t- = -... .----------------------------------------- Phone------------------------------------ <br /> ---- - - ---- ---- <br /> Address.. _-.. '--------•------- ---- ----------- - ------•------------------------------------------- <br /> Contractor's Name--------- • •-_�r.•- --- <br /> --------------------------------------------------------------------------------------------------------- Phone----••------ --------------- <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motpl ❑ Oth El <br /> Number of living units: _ __. Number of bedrooms --hl- Number of baths ._lt____ Lot size .�� . I_l! _ <br /> -- ------------------------- <br /> Water Supply: Public system Community system ❑ Private E] Depth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: Sand 17, 1 Gravel ❑ Sandy Loam Clay Loam E] Clay ❑ Adobe Hardpan ElPrevious Application Made: Yes E] No New Construction: Yes o ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted ifypubi'c se er is available within 200 feet 1 <br /> Septic 'ank: Distance from nearest well-_&."P <br /> _ _ -�Distaryc fromrfoun ?tion____ ____._____.Mat ri?l-----------------�A--- ____ <br /> g, ------ <br /> py No. of compartments-.--------.&.___...__Size :74 -_ Liquid depth-------* -.-_----:.Capacity--- Q.-----. <br /> Disposal Field: Distance from nearest we€i.................Distance from foundation------.-------------Distance to nearest lot line-_______________ <br /> ❑ Number of lines__________________________________Length of each line------------------------------Width of trench.-_-_----_____.______._ <br /> ------------ <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ <br /> Seepage Pit: Distance to nearest well---------------------- 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 /> . <br /> ❑ Size: Diameter------ ------------------------------Depth------------------------------------ --------------Liquid Capacity--------------------------•gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--___...______._____---.____-_--_-----. <br /> ❑ Distance to nearest lot line------------------------------ -----------------•------------•---•---------------------------------------------------------------------------- <br /> I,emooling dor repairing de.'be):----`- - ------ ------------- --------------------------------------------------- ------- ------•---------------------- ----------­-------------- <br /> - <br /> ---------. -------.--_-._ <br /> ----- <br /> r ---••--- r <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, nStates, and rules nd re ulations of the San Joaquin Local Health District. <br /> (Signed)..------ - -- -- -- � (Owner and/or Contractor) <br /> B'y:-------•-------- ------------------------------------------------------------------------------------------------------------------(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 /> APPLICATION ACCEPTED BY DATE5�� <br /> ---------------------------------------------------- <br /> REVIEWED BY------------- <br /> ------------------------------- <br /> BUILDING PERMIT ISSUED------------------------------------------ --------------------- ------------------------------------- DATE------- <br /> ---------------------------- <br /> Alterations and/or recommendations:--------------- ------ ----- ---- -------- --------------------------•----•-•---------------•-----•--- ••--------•----------------- <br /> --------------------- <br /> --- - - — -------------------------------------------------------•---------------------- <br /> --- <br /> •---- -- <br /> ---- ----- - -- --- -- <br /> --- -- ----- <br /> ---•-•-••-•-- -------------------------------------------------- ----------------- --------------------------------------------------------------------------- -•--- --------------- <br /> ------------------------------------------------------------------------------ ----------------------------------------- <br /> ,.0► <br /> FINAL INSPECTION BY:----- --------- _ x.- Date_---- -------- ------------------------- ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Streat 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 145446 ATWOOO 1254 <br />