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APPLICATION FOR SANITATION PERMIT Permit No- _____ z_ <br /> (Complete in Duplicate) 3/ f <br /> i Date Issued ----__ _/�a_ -,;_- <br /> ?Applica-�ion is hereby made to the San Joaqun Local Health District for a permit to construct and install the work herein described. <br /> his application is.made in compliance with.County Ordinance No. 549. j'2__ —170^l3 <br /> t(�a-o,0x�_a_�OW� . lbn.)ES.-9-oL .e.J�-- � f <br /> JOB ADDRESS AN/}D�LOCATION-Z-f)-6j)-, ��' '� ; F Y�t_� 1_01V f-/ �, ------------------------ -- <br /> Owner's Name---- �-r1lil Y f L'! � �/ '`----------------- ---- ------------------------------------- Phone------ <br /> Address.... <br /> ----.Address--------------- <br /> Contractor's <br /> ---------Contractor's Name--------------------------•-'----------------------------------------------------------------------------------------------- ----------------- Phone----------------------------------- <br /> Installation will serve: Residence ❑ Apartment House ❑ CommercialTrailer Court E] Motel ElOther E]Number of living units: _1)---*Number o/&roods _ . Number of baths __0__ Lot size ----------------------------------------------------------- <br /> Water Supply: Public system E] Community <br /> Jsystem ❑ Private ❑ Depth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam a, Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan [] N <br /> Previous Application Made: Yes ❑ No,'Q New Construction: Yes No ❑ <br /> d <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----rte---Distance from�o'undation___ �"'-_- _-.Materiaf___� ----- -------- <br /> No. of compartments-----r. --- --------------Size-----J__-_Ur�-------------Liquid depth------ --_- _--- <br /> -----:Capacity/0__60­___'0W <br /> Disposal Field: Distance from nearest jell.................Distance from foundation__ Distance to nearest lot line___-____________ <br /> Number o{ lines___._- /____ ________________Length of each line___W �__ Width of trench-_s _- ��___-_:-______.__ <br /> r: fp � – <br /> Type of filter material----- �t�_______Depth of filter material-__- _ __________To.tal length__ _ ______________ <br /> i Seepage Pit.- Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line______-_________ <br /> ❑ Number of pits----------------------Lining material-----_-----------------Size: Diameter-------------.--------:.Depth--------------------------------- <br /> i Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- C( <br /> =4 Size: Diameter-------------------- ---De th------------------------------ ---_Li Liquid Capacity c1 <br /> ❑ p Q p Y gals. <br /> Privy: Distance from nearest well--- - -- ------ -------------------------Distance from nearest building--------------------- -----------------� m <br /> ❑'- Distance to nearest lot line----------------------------------------------------------------------- -------.---------------------------=----- Vn <br /> Remodeling and/or repairing (describe)--------------------------------------------------------------------------------------------------------------- ------------------ - <br /> -------------- .----------------------------------------------------•-----•--------------------••-------------------------------- <br /> E <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, <br /> IN <br /> (Signed) ', c ";' <br /> ------------:-----------------------(Owner and/or Contractor) <br /> By:...�et_zt-- __ .: f, - Title <br /> --------------------------- <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 /> h <br /> APPLICATION ACCEPTED BY P -`------------------------------------------------------- DATE------- <br /> fx- - ------------------- <br /> - <br /> - <br /> ,. REVIEWED BY--------------------- ----------- - _ DATE-- _ _..-------- <br /> ------------- - - ----------------------------------------- <br /> BUILDING PERMIT ISSUED DATE -•------ ---------- <br /> Alterationsand/or recommendations----------------------------------------------- -----•_---_------------------------------------------------------------•------_----•-•------------------------ <br /> ------- ----r------------------------------------=------------ - _ <br /> -- -� - -� ----'--OC- 4�-- 'T+f----- �---�-h-a+"f- -e` ;--- f--�r-..;P- -- <br /> --------------- <br /> - -�- - --••-----••--------•-------------•------------------`------ <br /> F -I <br /> ---04( I- --------------------------------------- ----------------------------- <br /> FINAL <br /> ---------------------------FINAL INSPECTION BY:._ t- _ --;-. !. _-- - ------------- Date-------�= --,. _ \ <br /> t ----------------------- <br />` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street 1 <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />