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APPLICATION FOR SANITATION PERMIT Permit No. ..1..- __ __�.Q <br /> (Complete in.Duplicate) 1 67 <br /> Date Issued _________ _4f <br /> f <br /> Applicaa•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 ith County Ordinance No. 549. f, } <br /> JOB ADDRESS AND�LOnCATIO "`�'!"'-------- --- <br /> - *� <br /> Owner s Name---- f--- +---• - - -- -------------•---------•----------- -------------------�-------------------------=-----�-1---- Phone----------------------------.....--- <br /> � , <br /> Address-------v'l .t.... ... ,?�'. '"� .... = "---•------------------------------------•---------•-------- <br /> Contractor's Name_.- Phone. <br /> Installation will serve: Residence ❑ Apar ment House ❑ Commercial ❑ Trailer Court Q( Motel ❑ Other ❑ <br /> Number of living units: -7 Number of bedrooms -------- Number of baths _______. Lot size ----------_--------10-_�__ -------------- <br /> Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table 4_0_ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam A Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No % New Construction. Yes ;X 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------7S_._Distance from foundation______-_ ---------Material------- - ---------- _______________________ <br /> odNo. of compartments----_---- '_ -----------Size-,'/,.XI_9--)_10------Liquid depth------------L/-----------Capacity__.9;�_Vd__a.... <br /> Disposal Field: Distance from nearest well-----'f__S--- <br /> _Distance from foundation------_"''-------Distance to nearest lot line--- <br /> Number of lines_____________ ___ ____________Length of each line------------------------------Width of <br /> _._ t <br /> rench_______ <br /> D .�_ S - _--------------------- <br /> Type <br /> ___ . -_____ <br /> -_-_-_-_- <br /> _Type of filter material___ _ _____ epth of filter material____.__L$_ _-_-_Total leng S ___________ <br /> Seepage Pit: Distance to neprest well-----_-----------------Distance from foundation--------------------Distance to nearest lot line-___-__.______-_. <br /> ❑ Number of pits---------------- Lining material-----------------------Size: Diameter----------------------.Dept h----------------------_---------- <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 /> 0 Distance to nearest lot line----------------------------- ----------------------------------------- ------------------- - <br /> Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------- <br /> -----------------•-------•---------------------------------------------------------------------------•----•--•-----•---------------------------••---------------------------------------•------------------------------------ <br /> ---------------------•----------------------------------------------------------------------------------- •-------------------------------------------------------------------•---- ----------------------------------- <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinanceZSfa, laws, and rules d regulations o the San Joaquin Local Health District. <br /> (Signed)--- ------ ---------------------------- �waiii endfor Contractor) <br /> V. <br /> � �--�L: Title <br /> Y• ------- - - - -( )---------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in lam tion to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- __ DATE_._lV.-eP X- - <br /> REVIEWEDBY------------------------------------------------------------------ - ---•---•- -------- ------- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED---------------------------------- --------------------------------------------------- --------------- DATE------------------------------------------------------------ <br /> Alterations and/or recommend ations------------------------------------------------------------------------------------------------------------------------•------------------•-------•----------- <br /> -------------- -----------------------------------•-------------------------------------------------------------------------------------------•---•--•-••------•-•-------•-------------------------_.----------------- <br /> ----------------------------------------------------------------------•----•--•----------------------------------•------------------------------ -- -----•.-- <br /> FINAL INSPECTION BY:_.�� 001" Ct Date --- (0-----------------------------•--------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <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 /> EN9-2M Revised W-2100 <br />