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FOROFFICE USE <br /> s <br /> � � 12a--2'z°D D <br /> ----------- -------- ---------------------------------- APPLICATION FOR SANITATION PERMI Permit No. ...�.13........... <br /> --------------------- -•-------------------------------- (Complete in Duplicate) <br /> 0- <br /> This Permit Ex ires i Year From Date Issued Dote Issued ._' _�.. <br /> Application is hereby made to the San Joaquin Loca! 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 LOCATION___._. �__-.�-�_.-•---_��r_y� �,y�,�'i-��'_-�-��-�� .,�� <br /> Owner's Name. = •----------- -------------------------------------- - ----------Address..... <br /> Contractor's Name-'" ..................................... Phone----••.....------... <br /> ------------------------ ------------- <br /> Installation will serve: Residence E] partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of living units: -------. Number of bedrooms -------- Number of baths -------- Lot size ................................... '` ' <br /> ti �3iilt'7` <br /> Water Supply: Public system E] Community system ❑ p Private K Depth to Water Table _______- ft. ir r <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ 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___r_ <br /> P �64_Distance from foundation---lit) -------Material-PAA<�¢�_.,-��}-jy,�,�,• <br /> No. of compartments----------- <br /> __.__-_ ---_____Size�°�`�_9J e I(s i uid de th_____ 1 <br /> 9 P. ` ---------------Capacity_ gA...... <br /> Disposal Field: Distance from nearest welL--���__'i:"Distance from foundation.16_..rk....Distance to nearest lot Gne.__'`__�:::� <br /> Number of lines--------- ----------±_-__-___-Length of each line---J5L0_!______________Width of trench.._ _ ' .�E <br /> Type of filter material._jZV.C_e,____Depth of filter material_____- --------Total length------161...................... , <br /> Seepage Pit: Distance to nearest well_-------______'------Distance from foundation....................Distance to nearest lot line----------------- <br /> ElNumber of pits--------------1-------Lining material----------------------.Size: Diameter------_-----------------Depth--------------------------------- <br /> i�rJ1 <br /> > <br /> Cesspool: Distance from nearest well------- ___-_Distance from.foundation____________________Lining material------------------------------------- <br /> El Size: Diameter :----------- ---------I-.......Depth----------------------------------------------------Liquid Capacity_-------------------------gals. <br /> Privy: Distance from Inearest well-------._?_____..____---_______ __________Distance from nearest building---------------------------- <br /> ❑ Distance to nearest lot line____.-k____________ ___ <br /> 1{ ----- --•------_------------ ---------••-------------------....-•--•---------------------•---••--- <br /> Remodeling and/or repairing (des ribe)_______ ______________________r-*- ---•-_--__- <br /> ----------------•---------------------•------ <br /> ------------------------ ----- <br /> ............... �-......-•----- ---------------- --•--------------------••------------------•--------•-----------------------•----------------------- <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, State laws, and rules and regulations of the:San Joaquin Local-Health District.- I <br /> (signed) '! ----•- .d °`r <br /> -- ---� _ '� � �+_____(Owner end/or Contractor) <br /> i <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- = s r ---------- - DATE _ <br /> REVIEWED BY.. - <br /> - s,-- -------------•------------------------------------ ----------- DATE <br /> BUILDING PERMIT ISSUED---------------------------------------------------•---•- ------------------------------------------ DATE <br /> Alterations and/or recommendations:------------------------------- -------------- --------•-•-•-------••-•----------- <br /> --------•-•---------•------•---------------• ----------- ---•-----------------------------•---•---------•------- ------------••----------•-••-•-----------•--•---••--------------................... <br /> ------------------------------ <br /> --------------------------------------- <br /> -•-----•--•----------•--•---------------------------------•-----••--•- <br /> FINAL INSPECTION BY:.--- ........ -- ---- ----------------••------ Date.------------ <br /> 0/- /- ------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> r <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 51 REVISED 0.59 1%M 5-61 ATLAS <br />