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APPLICATION FOR SANITATION PERMIT Permit No. -- <br /> (Complete in Duplicate) Date. Issued --- <br /> Application 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 with County Ordinance No. <br /> 9. <br /> ° ''' "'` <br /> JOB ADDRESS AND LOCATION----- -'�-_ <br /> �� - ^ <br /> - _------ _ ""-- = <br /> Af <br /> Owner's Name__rr -- ----------------------------------------------------- Phone------------------------------------ <br /> ----------- =- <br /> Address. ": a : `---------------=------=------------------------------------------ ------------------------------- ---------- <br /> Contractor's Name___ _ � "� �" <br /> ----------------------------------- Phone - ----- - <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial. Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size _______ !_o-_______.____. <br /> Water Supply: Public system Community system '❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No?S New Construction: 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 w —ell__ _ -—Distance from foundation____--- _`�__..Material______ _ .;;_ <br /> No. of compartments--------..__ ----Liquid depth....... --------Capacity___I,__ <br /> Disposal Field: Distance from nearest well :• Distance from foundation------- --------Distance to nearest lot line.__: ________ <br /> Number of lines--!- _____ diw <br /> ¢____ :Y____.__Length of each line___-----�'_.� _ _ _.Width of trench__-___ ' _ "____---------- <br /> Type of-filter material____x ____ Depth of filter material_-____Z "--------Total length___._._.- "E., -_______________s___ <br /> Seepage Pit Distance to nearest well----------------------Distance from foundation--------.__.--------Distance to nearest lot line----------------- <br /> Number of pits----------------------Lining material----------------------,Size: .Diameter------------------------Depth--------------------------------- <br /> Cesspool: Distance from .nearest well-----------------Distance from foundation---------------------Lining material_-_____.____________.______._.______. <br /> ❑ Size: Diameter--------------------------------------Depth----------------------=------- ---------------------Liquid Capacity----------------------------gals.1 <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____________________ <br /> ❑ Distance to nearest lotline------------ ------------------------------------------------------•-------------------------------------------------------------------------- <br /> a <br /> Remodelingand/or repairing (describe)=---------- ----------------------------------------------•----------------------------------------------------------------------------------------------- <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 ofthe S n Joaquin Local Health District. <br /> - -,------=-- '�--- = -------- ' ,= --------------------------- <br /> (Signed].. - /or Contractor) <br /> ---------- ---=------------------------------------------------- {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 /> a <br /> APPLICATION ACCEPTED BY---- -------------------------------------------------------------------- DATE l <br /> REVIEWEDBY--------------------------------- DATE------�----_.v---------------------------------------- <br /> BUILDING PERMIT ISSUED---------------------- ------ ------------------------- DATES <br /> Alterationsand/or recommendations:-------------------------------------- -------------------- -------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> p� - <br /> FINAL INSPECTION BY---------S�"__------------ <br /> 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 8-51 Revised W-2100 <br />