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APPLICATION FOR SANITATION PERMIT Permit N . -------- <br /> i� (Complete in Duplicate) Date lssue S-3 <br /> Application is hereby,made,to,the San-Joaquin,Local-Health District for a permit t construct and install the wo h ein described. <br /> This application is made in compliance with County Ordinance No. 549. : <br /> JOB ADDRESS AND; CATION---- / ------------- --•------------------------------------------- ---- <br /> {� f - 6,0 <br /> Owner's Name ----� Qh �. �.-� <br /> Phone---------` •-------- <br /> I.. i <br /> Address - --- -------- -- - <br /> s y <br /> Contractor's Name------------------------- - f------ ------.--- Phone_ <br /> a - ----- _�------------------ <br /> Installation will serve:' Residence Apartment ouse ❑ Commercial;❑ Trailer Court E] Motel LlOther E] <br /> Number of living units: _ _ Number of bedrooms .�" Number oftbaths Lot size ____4�Q Y_ �r�---------------- -- <br /> Water Supply: Public system' Community system ❑ Private ❑ Depth to Water Table��ft. <br /> Character of soil to a depthof 3 feet. Sand❑ Gravel E] Sandy Loam El Clay Loam ❑ Clay E] Adoba- Hardpan ❑ '" <br /> Previous Applicatiori'Made: Yes ❑ Nox New Construction: Yes ❑ No i <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank:r' i Distance from nearest we1,1.g-_,,E!ok _-Distance from foundation__- -------------Material__...__________________________________________ <br /> No. of compartment-s-------------�-----------Size-----"--------------------------Liquid depth------------- -- ---------Capacity----------------------- <br /> Disposal:FielS4 Distance from nearest welhr�_ -_Di6tance from foundation__-le9___""-------Distance to nearest lot line_..,T` _____. �. <br /> Number of lines-----------------------------------Length of each line------------------------------Width of trench---------------------------------- <br /> Oi7"_ Type of filter material---------- --------------Depth of filter material-----------------------Total length------------------------------------------ <br /> Seepage Pit: Distancerto­nearest welly _,Distance f om-foAndation_/,_______-_Dist fce to nearest lot line----� � <br /> 7r <br /> `* <br /> Number of pits.---I----------- Lining materiav��tr __Size: Diameter-.;- .--- Depth---i ________-- - -" <br /> !� K ` <br /> Cesspool: Distance from nearest well----------__-----Distance from foundation---_---------------Lining material----".-_-______________"____-.__.__ ' <br /> ❑ Size: Diameter-'_ `--------------------------_--___Depth----------------------------------------------------Liquid Capacity------------------- --------gals. <br /> Privy: Distance from nearest well-----------____w:-----------------.-------------Distance from nearest building_._"____".__."--------_-_____.__..______- f <br /> ❑ Distance to nearest lot Iine--------------------------------------------------------------------------------------------------------------- --------- ------------- <br /> Remodeling and/or repairing (describe);-----------� ' -----------------------------------------------=--------... --------•----"---------------------- ------------------- <br /> 4 <br /> ----------------- <br /> ----------•--•-------•-•---------------------------------------------------- --- <br /> --------------------------•--------------------------------- <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I <br /> ordinances, ,lawsd rules an ere cations of the San Joaquin Local Health District. <br /> C (Signed)--- - _f ---- -- ---(Owner�apd/or Contractor) <br /> I <br /> gY - - -• - <br /> (Title) ------ - ' <br /> (Plot plan, showing six Of lot, ocation of system in relation to wells, buildings, etc., can be placed on rev re se�si 4 I <br /> r-. FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----;_i -------- ------------------------ --------------------------------------- DATE-:=.; <br /> - -1 ......_.. <br /> REVIEWED BY------------------ ----- <br /> 3 DATE----- ------------------•---------------------------- <br /> BUILDING PERMIT ISSUED--------- <br /> -------=--- ---------- ----------------------------------------------------------------- DATE------�- � ----------------------- = <br /> Alterationsand/or recommendations:_k------------------------ -------------------------------------------------­--------------------•--------------------------------------------------------- <br /> �) <br /> -------------------------------------------------•-----------------------------------------------------------------------------------•-------------------- ! <br /> ! --------------------------• •-•.•- ------ <br /> 1 ' • ----- ---------------------------------------------------- <br /> t <br /> i "..__._"_._"_"_"-."__"-"_________________________"-______.___..___.._._____ <br /> _ l <br /> FINAL INSPECTION BY--------------- 7 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 10-52 Revised W-2100 <br />