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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complefe in Duplicate) <br /> \ Date Issued ___&_ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct(rd install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549.13 '�0,4 -" <br /> r <br /> JOB ADDRESS AND LOCATION---- -_ ±- '_� �.� -- �_ <br /> Owner's Name. ------------------ ---- <br /> Address d -- ------� ' ----- ------ <br /> amu, <br /> t <br /> Contractor's Name--- -- * ------• -------------------------- Phone <br /> Installation will serve: Residence [4-'-Xpartment House ❑ , Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___1___ Number of bedrooms ___ _ Number of baths _614_7Lot size � '-•� --�'v- � <br /> - ------------------------------------------------- <br /> > j <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table :}_--___ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No [ New Construction: Yes [ie'o ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - <br /> Septic T"nk: Distance from nearest well..-. -____-Distance from foundation--./ ____-_.Material________ ________ __ ._ . ______- <br /> ;/ No. of compartments........ ----______Size X1---X_ X_ liquid depth._.____.'_ __-__Capacity____�'�' -".�� <br /> Disposal ield: Distance from nearest welL_F�-_I._Distance from foundation__-- _ istance to nearest lot line____ ---±' ` <br /> Number of lines----------- --------Length of each line__'F__!r__ . - <br /> -------Width of french.___ <br /> Type of filter materia�Tt__ _-Depth of filter material t <br /> ____.Total length------I--- <br /> Seepage Pit: Distance to nearest well-----_----------------Distance from foundation--------------------Distance to nearest lot line----------------- b <br /> ❑ Number of pits----- ---Lining material-----------------------Size: Diameter----------------------Depth----.-------.-------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------------------- ---.__.___.__ d <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Uquid Capacity----------------------------gals. <br /> Privy: Distance from neatest well-------------------------------------------------Distance from nearest building____...__.__._______________..____.___-_ <br /> ❑ Distance to nearest lot line----------------------------------------------- ------------------ --------------------------- ------------------------------------------- <br /> Remodel ing <br /> ------------------Remodeling and/or repairing {de fibe):--------17-------------------------------ef_----------------e'-'`---------------------------------------------••--•-----------•---------------------- <br /> ?4F I_ - - ------­-------- .---- ---------------------. ;: ----------------------- --------------- <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, Stafne,laws, d rules nd regulations of the San Joaquin Local Health District. <br /> (Signed ..-------`--• --- ---- -- ---- -------------------------------------------------------------------(Owner and/or Contractor) <br /> By:------------------------------------------------------------------------------------------------------------------------------------(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--------------------------------------------1- ---------------------------------------------- DATE----- --/­�7 <br /> REVIEWEDBY--------------------- ---------------------------------------------------------------------------------------------------- -- DATE--------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-----------------------------------------I------------------------------------------------------------ DATE------ ---------------------------- <br /> ! nd/or recommendations: ---------- ------- ---- ---{---------------------------------------------- <br /> I[ r ------------- <br /> ��- --�ratia�n� � �--- --- �.,f�---- :�'�•--f��__:�R.�.�---------------- � <br /> ---------- ! - --------------- xb --------------- ------ ---- A -- - ` <br /> ----- -- - ------ <br /> ------------------------------J-------- ----------------------------- r <br /> FINAL INSPECTION BY:----------- ---------- Date---- -u.1 -g- --57z------------- ------ <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 �0-52 Revised W-2100 <br />