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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued ------ <br /> Applica4-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein c1escribZ\, <br /> This.application-is-m.ad.6 in compliance with County Ordinance ". 549. <br /> JOB ADDRESS AND CATION- ----- - - --------- ------------------- -- ------------------------------------------ <br /> ------------- <br /> Owner's Name_ - -- -------------- - - ---- - ------------------------- ------------------------- --------=--------------- Phone------------------------------...- <br /> Address <br /> hone---------------------------------- <br /> Address----------- --- ------ -- -- ---------------------------- ---- --- ----------------- -----------------------I----------------------------------------------------------;--------- <br /> Contractor's Name---- i�------- -------------------------------------------------------- ------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence <br /> parfrnenf House E] Commercial E] Trailer Court [3 Motel E] Other C] <br /> Number of living units- Number of bedrooms -3--- Number of baths _/--- Lot size __1aa__X.J40--------------------------------- <br /> Water Supply: " El <br /> Public'sysfem ' Community system E]._ PrivateA Depth to Wafer Table !__.Q_ ft. <br /> Character of soil to a depth of 3 feet: Sand E] GravelX Sandy Loa rp� Clay Loam E] Clay E] Adobe E] Hardpan 0 <br /> Previous Application Made: Yes E] N O� New Construction No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> IN n e p <br /> (No sepficjank.or�cessp�o <br /> i _?I,permitt d if public ;ewer..is available within 00 feet. <br /> �"a_ —0" "T C <br /> c <br /> T <br /> Septic Tank: nce r n --- Distance from foundation------/0-------Material________t�!� -- ------- <br /> n e <br /> ar, �_Z..........size--------------------------------Liquid clepth------------_-----------Capacity----------------------- <br /> Disposal Fief f nce rom nearest weIJ-----6-0--.-.Distance from foundation_ _1_ _0___f._--Distance to nearest lot line �_ ae <br /> 'be r 0� lines___._____ <br /> � <br /> .5. --Width of frenc <br /> / :----Total length----- -------------- <br /> mber o� lines----------- ----- Length of each line____ <br /> P, F filter material---- 75�_ epth of filter material-------- <br /> T filter <br /> it" rnat"ia <br /> e oT <br /> Seepage Pit: Distance to nearest well_ViP---------Distance from f un 'o f f I <br /> or 9cy o nearest o <br /> FT NUMber of pits_____._____________-------------Lining material_ Diameter—& _jr____.Depth------- R_______ <br /> Cesspool: istanCe from nearest well-------------- --Distance from undation ___._-.Lining material-_ --------------------------------- <br /> Size. Diameter________________ <br /> ia meter-------------------------- -----------Depth__ ------ ------Liquid Capacity--------------------- ----- <br /> m'n f w�ll from <br /> Distance fro eares --------------- -- -------------------------------Distance nearest building______________________________.__________. <br /> ------------------ ------- ---------------- <br /> Eli Distance to nearest lot line ------------------------------- ------------------------ ---- <br /> I �, ep 4 <br /> Remoto d/oG rpaiHng (describe'. 44'a-0 -- --------- ------------- bL8/� <br /> a an -- ------------- <br /> --------------- <br /> --------- <br /> r --— ---------- <br /> ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------- <br /> -------------------------------------------------------------------------------------------------------------------------------------*------------------------------------------------------------*---------------------- <br /> I hereby certify that I have prepared this application and that the work will 6e-done in accordance with San Joaquin'County <br /> ordinances, State laws,'and rules and regulations of e;San Joaquin Locial Health District. <br /> 7�V!, Pf <br /> (Signe8)---- -----------------------11. ------ --- -------- ------------------------------:----------------------------(Owner and/or Contractor) <br /> I - ---------"___ ------ <br /> 4By:----------------------P--------------------------------------------------------------------------------------------------------------(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------------------------ <br /> - BY----------------------- ---- ---- - --- --- --- ----------------------------------------- DATE------- <br /> -----Z------------------- <br /> -------------------- <br /> - <br /> REVIEWED BY--------------------------------------------------- -- - --- - --- ----- I- ---.. DATE---- ... <br /> -BUILDATE-- - ---------------------------- <br /> Alterations <br /> DING PERMIT ISSUED-------------------------------- -------------------------------------------------------- - -------- <br /> Alterations and/or recommendations:--------- -------- ----------- -:-------------------------------------------------------------------------------------------------------------- <br /> -----------7------------------------------------------------------I--------------------------------- ------------------------------ ----------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------- ---------------•-----------=-------------------•---------i--------------------------------------------------------- ----------------------------i-------------------------------------- <br /> ------------------------------ -------- ---------------------------------------- ------ ---------- ---------------------------------- ------------------------ - -------------------------------------------------- <br /> FINALINSPECTION BY------ - -- ----------------------------------------------------- Date---------------------------------------------- -------------------- --------- <br /> SAN <br /> ------------ <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 Revised W-2100 <br />