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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued <br /> .......... <br /> Applica4ion is hereby made to the San Joaquin Local Health Disfpilct for a permit to construct and install the work herein described. <br /> This application is made in compliance ounty inanc 149, <br /> b AtNESS-AND-LOCATION­ <br /> � -- ------------ --- ------q---------------I------A <br /> Owner's Na2'd -------------- -------- ------ ------------------ -------- ---- ----- Phone----------------------------------- <br /> e- (--------------------- - ..: . <br /> -----------­-------- --­-------------------------- --------- <br /> Address---]F�­/-­- ---------------------------------- <br /> Contractor's Nome--- --- --- ---- ---- - -------------------4,,A ---—------ <br /> -------- ---- Phon <br /> Installation will serve: ,Residence A---Xpar'tment House [] Commercial E] Trailer Co'urt E] Motel [] Other E] <br /> Number of living units: Number of bedrooms --?--_- Nunnber of baths -I---- Lot!size 4-1ir---A------[Al ---------------------- <br /> Water Supply: 'Public"system'D Community system [I' Private'&---Depth to Water Table-J& ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel F] Sandy Loam E] Clay Loam El Clay E] Adobe6 Hardpan E] <br /> Previous Application Made: Yes F1 No New Construction: Yes�­No El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank'or cesspool permitted if public sewer is available within 200 feet.). <br /> , . ­�:� <br /> Se Tank: Dis.tance from nearest well_ laferial-7cc"InIn ---- <br /> Distance from foundation____/-0---------Iv <br /> Septic <br /> No. of compartments_..._-- -----Size-.-g'('-7-K-�4--------Liquid depth---3-_1- ------_----Capacity--- P-------- <br /> D;spos'al Field: Distance from nearest well-------------- ---Disfance from foundation---------------------Distance to nearest lot line_________________ T <br /> ❑ <br /> ine----------------- <br /> El Number of lines-------------------------------------Length of each line...­­----------------------Width of french----------------------------------- <br /> Type of filter material_________________________Depth of filter material-_____-__.._____ Total length------------------------------------------- <br /> Seepage Pit: Distance to nearest well-.--------------------Distance from foundation---------------­--Distance to nearest lot line._-_____________ <br /> ❑ <br /> ine----------------- <br /> El Number of pits----------------------Lining material----------------------.Size: Diameter------------:-----------Depth--------------------------------- <br /> cesspool: Distance from nearest well-----------------Distance from foundation._._______________. Lining material__.__.____..__.____.______________- <br /> -----------------------------------Liquid Capacity-----------L <br /> Size: Diameter:---------------------------I.,------I <br /> Privy: Distance from nearest well------------------------------------------------Distance fr6m­hearest•building__________________________-______---_____. <br /> ❑ -Distance <br /> uilding----------------------------------------- <br /> -Distance fo nearest lot-line------- --------------- -- - - - <br /> Remodelin ------------------------------------------------------- <br /> ----------- ----I--------- ------ ------------------------------------------------ <br /> g and/or repairing (clescr;be)- ------- <br /> ----------- ---------------------------L------------------- ---------- <br /> ------- -- --- -----•----- <br /> ------- ------------------------------------------------------------------------------ <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> 1�� <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, ate laws,-.and rules and regulations of the Si-n-Joaquin Local Health District. <br /> ---- ----------------------------------(Owne, anal or-eontracforl, <br /> (Signed)--- ------- <br /> --- - ------ <br /> --------- ----------------------------------------(Title):--------- ----------------- <br /> By:-------- ........ <br /> (Plot plan, showing size of lot, locaflo'n of system in relation to wells, buildings, etc., can,bg place on reverse side). <br /> FOR DEPARTMENT USE-ONLY <br /> APPLICATIONACCEPTED By-------- -- ---- -------------------------------------------------------•-------------- DATE- ----------------- ------------- --------------- <br /> -3 <br /> REVIEWED BY------------------------------ ----------- --------------------------------------------- DATE_--—---------- ------------------------------------- <br /> ---------------------- <br /> i:ij - I- - - ------------ DA °L "4,,r% ----------------------- --------------------- <br /> BUILDING PERMIT ISSUED-------------------------------------------------�t----------------•-•-•------------------ <br /> Alterationsand/or recommendations:------- -------------------------- ----------- -----------------L------- --------------------•----------•----•---•--- ----••--•-...---_...---••------- <br /> ----------------- <br /> -------­.............I------- <br /> ------------------------------------------------------------------------------------------------- ---------------------------- ---------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------- ------- <br /> ----------------------------------------------------------------------- <br /> --------------------------------------I---------------------------------- <br /> ----------------­-------------------- --------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------­-------- --------------------------------�\- ----------------I----------------------I------------------------------­------- ---------------------- --------------------------------- <br /> -7 FINAL INSPECTION-BY:----------- ------- ------------------------------ ............ Date.-------- -------------------------------------------- <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 - I <br />