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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued ---- -- <br /> Apprp�lcafion is hereby made to the Son 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. 549. <br /> ----------------------------------------------- <br /> JOB ADDRESS AND LOCATO - -------- --------------------------------------------- <br /> aN <br /> 7 <br /> Phone ------------ <br /> ........ ... <br /> Owner's Name---- -- --------... ... -- --- ---------_-------------------------------------- -------------------------------------------- <br /> Address------- ---------------------------------------------------------------------------------------- ------------------------------------------------ <br /> Contractor's Name--------- -------- -------------------------------------------- Phone--v ----------------------- <br /> Installation will serve: Residence Apartment House E] Commercial 0 Trailer Court E] Motels E] Other E] <br /> 94P <br /> Number of living units: _/_ Number of bedrooms _/--- Number of baths /--- Lot size --- ------------------------------------------ <br /> Water Supply: Public'system E] -Community system [] Private,' 'DeptVto'W6feir Table t. <br /> Character of soil to a depth of 3 feet Sand E] Gravel E] Sandy Loam E] Clay Loam E] Clay E] Adob aX Hardpan E] <br /> Previous Application Made:. Yes E] NoNew Construction: Yes El No <br /> X oex <br /> TYPE.OF INSTALLATION AND SPECIFICATION' S: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well----4P---------Distance from foundation------41A_,__Mafer- I <br /> #1 .0 21------------------------- ---------- <br /> No. of compartments--------:;–-------------Size-474.7,YVA...X-57-Liquid cl,p�h.........V._-�------- Capacity---- 09 <br /> Disposal Field: Distance-from nearest well Distance from foundation____A4--------Distance to nearest lot line______._.___ <br /> Number <br /> ine___--------- <br /> Number of lines-------------/--- -------------Length of each line-------4d_-------------.Width of french-----2--el................f-- <br /> Type of filter material___ R.4-c-le-----Depth of filter material------/e. {_____Total' length----___40_--------------------------- <br /> Seepage <br /> ength-------40_--------------------- <br /> Seepage Pit: Distance to neare d sf well____________ ______Distance from foundation______-_____.-_.___ Distance to nearest lot line_.._______.____._ <br /> ❑ <br /> ine----------------- <br /> El Number of pits----------------------Lining material---------------------------Size: Diamet6r------------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well_________________Distance from foundation._.._.__.__.____--- Lining material--______.._.--__------..------------ - <br /> 0 Size. Diameter__:--I---------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well--------------------------------------------------Distance from nearest building.__-_.___________-_____-__--__-__..___. <br /> ❑ <br /> uilding------------------------------------------ <br /> 0 Distance to nearest lot line---------------------------------------------- ----------------------------------------------------------------------------- -- --------- <br /> Remodeling a <br /> - --------- <br /> Remodelinga nd/or repairing (describe):--------- -------------------------------------------------------------------------------------- ------------------------------------ --------------- <br /> --------------------------------------------------------------I-------------------------------------------------------------------------------------------------------------------------------------------------------------- <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 of the San Joaquin Local Health District. <br /> (Signed)___ _ 4i ____.(O- ------- � <br /> nEr and/or ont f0 <br /> r) <br /> E ----------------------------------------------------------------(Title)-- <br /> (Plot plan, showing size of lot locatipf of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ------------- - -------------------------------=-- ---------------------------------------- D ATE :- <br /> ----------------------------------------------------------------- <br /> ----- <br /> REVIEWED BY---------------------------V--------:1----------------- ---------------------------------------------------- DAT 1 -------- <br /> BUILDING <br /> - ----BUILDING PERMIT ISSUED------------------------------------------ ----------------------------------------------------------- DATE..---------V----------------------------------------------- <br /> Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------I-------- <br /> ---------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ----------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------- --------------------------------------------------­­---------1------------­­--------I------------------------- <br /> ------------------------------------------- ------------------I----------- ----------- --------------------------­--------------------------------------------------------------------------------------------- -------- <br /> FINAL INSPECTION-BY:---------- ---------------------------- Date-.,,-07/_;0 - ------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Was+ Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California 64", California Manteca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 <br />