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APPLICATION FOR SANITATION PERMIT Permit No. .. <br /> (Complete in Duplicate) <br /> Date Issued __ <br /> Applica ion 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. 549. <br /> -- I <br /> JOB ADDRESS AND LOCATION------ - �----- - -- ---------------- Q 4` <br /> ----- -- - -- <br /> / ------------ --------- <br /> Owner's Name -------------- 0'2------- �.�", Phone <br /> _ - - - = . <br /> Address /� <br /> ---------- <br /> --- <br /> ---••- s .. /_ <br /> ------- --------------------- ------••---------------------------------......_ <br /> Contractor's Name---------•---- — 0 i� h _ - �} g <br />' Phone 7 J.6_,9.7--- <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 <br /> Water Supply: Public system ❑ Community system ❑ Private Of Depth to Water Table 17.1j0 ft. <br /> Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe k Hardpan ❑ <br /> Previous Application Made: Yes ❑ No X New Construction: Yes [❑ No ❑ , DC. ,, <br /> C <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: • • )'! "` `"`�` �-- 1 <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) , ) <br /> Uiis T- Distance from nearest well_________________Distance from foundation-------------------.Material--__.__.+--------------------­------ <br /> j <br /> _.__-___ _ ___. <br /> ---••----- = <br /> No. of compartments Size _._Liquid depth---------------- ------- Capacity------------- <br /> posal .field: Distance from nearest well---- Distance from foundation___44�_ '--" <br /> _ . __.Distance #o nearest lot Iine____�____..___ <br /> Number of lines------I_------ " ------ ---------Length of each line---/40' --_ - .Z •f� <br /> u - Width n french •*►" <br /> ,d.... Type of filter materiaL_��,iL_--_-�! ."-"Depth of filter-material______L g.rr _Total length__-_____�-`��__ <br /> Seepage Pit: Distance to nearest well__A_�__Distance from�oudation___ Dis#ante to nearest lot line_____-- - .Number of pits._.r< t______________Lining material-_- Size: Diameter___ ,c ---- Depth_�Ci..c ------------- <br /> Cesspool: Distance from nearest well-------------_---Distance from foundation--------------------Lining material <br /> Diameter--------------------------------------Depth---------------------------------- Liquid Capacity gals. <br /> Privy: Distance from nearest well_"______________________________________________Distance from nearest b0clin <br /> ❑ Distance to nearest lot line-------_--------------------------------------•----- <br /> Remodeling and/or repairing (describe)_____________________.____ <br /> ------------------------------------------------------- <br /> --------•----------------------------------------------•------------------------------------------------------•--------------------------------------------------------------•------------------------------------------ <br /> I hereby certif .-#laat I have repared thi application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State ws;an rule .hand regulati ns of the San quiin Local Heal h District. <br /> (signed) _ _ V .. Contractor) <br /> fi <br /> -- for <br /> By:--•------------------•-•-------------------- ---- <br /> - - ----- - ar,Co <br /> �c„rl ��------- <br /> (Plot plan, showing size of lac; location of system in relatio o wells, buildings, et ., can be pladed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------------------- ----------------------------------------------- DATE-------------- <br /> REVIEWEDBY-------- -------------------------------------------I----------------------------------------------------------------------- DATE <br /> BUILDING PERMIT ISSUED-----------------------•-------------- •-------------------- DATE <br /> ----------------------- -- <br /> Alterations and/or recommendations:---------------------------------- . <br /> -------- ------------------------ ---------------------------•-------••------------------------------------•---------------------- <br /> ---I------------------------------------------ --------- ----------------- ------ ------ -:----- x--------•------------•-------- --------------------------------.. <br /> = -------------------- _4 ------------•------------------------------------- ----------------1 -- °�-�- <br /> 41!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" Sfreef <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ; - Revised W-2100 <br />