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1 f <br /> APPLICATION FOR SANITATION PERMIT Permit No. �_-�_6-`----- � <br /> (Complefe in Duplicate) r <br /> GAJ✓ _ j Date Issued <br /> ,�:5�, '�Ci"�:�'Z_ C�4�.✓c_.r S �Q L ' � <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 /> JOB ADDRESS AND LO ATION...-- -•---- r .-•-•�- ---- -- ---- -- --�----.------•--------------- <br /> Owner's Name---- - -- --------- --- ---- ----------- one----------------------:------------- <br /> Address--------------_-- <br /> ------------Address--------------_-- ............... --------- ------------ -------------------------­- ---------- -------------------------------------------------------- <br /> Contractor's Name--------------- --- `----- --------'------------------------------------------------------ Phone____------------------------------- j <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 <br /> Water Supply: Public system ❑ Community system ❑ Private [J--ISepth to Water T ble ________ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ <br /> TYPE'OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic fank or cesspool permitted if public sewer is available within 200 feet.) b ,� <br /> Septic Tank: Distance from nearest well_________________Distance from foundation____..______-___-__.Material-------------------------------------------------- <br /> Ilk <br /> F1 No.!of compartments--- ------Size---------------•---------------_Liquid depth--------------------------Capacity----------------- <br /> k <br /> Disposal field: Distance from nearest well---------------__Distance from foundation--------------------Distance to nearest lot line----------------- I <br /> ❑ Number of lines-----------------------------------Length of each line-------------------------------Width of trench-- ------ <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ <br /> Seepage 1 pnearest well-------------_________Distance from foundation--------------------Distance to nearest lot line___._____________ <br /> See a e Pit: lumber of its Linin material________________ __Size: Diameter__-__ -__ _------------De th-_::_..__•__..___ __------------ <br /> f <br /> _________ <br /> P 9 <br />" Cesspool! - Distance from neare t well's-�- )stance from f gun, t'Ry��. - -._.Lining materia!_______ f!�,G`�u------ <br /> Sire:-Diameter <br /> ____. <br /> I <br /> 5ire: Diameter-==�Gk -=----- --Depth---=•-=------ - "•-= Liquid Ca acity-j&- `----------gals. <br /> Pri"vy:' Distance from reares we1L___--------------s------------------------------_-. istance from nearest building__ _ - <br /> ❑ Distance to nearest lot line------------------------------------------------------------------- <br /> { <br /> Remodeling and/or repairing (describe)------------------ih• p-- _ _ ------ -1-'_,44------ -------- - <br /> --•---•-------------------------------=------------------ ---------- 1 <br /> ------------- 'L- 0t" -----: <br /> ------------------ - <br /> ------------------- -----•---••----------------------------------------------------------------------------------- i <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)---- V S .. _________Owner and/or Contractor <br /> By:-----------•-------------------------- -------- ----------------------------` - ---(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 /> APPLICATION ACCEPTED BY--------------------------- ----------•- •----------- DATE----------- -7---- -------------------- <br /> REVIEWEDBY---------------------------------------------•------------------------------------------------------------------------------- DATE----------------------------------------------- ------ <br /> BUILDING <br /> -- ----- <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------------------- <br /> ----------------- <br /> Alterations and/or recommendations---------------------------------------------- ------•---•• •-•------------..-1--- -------•-------••---------------------------------------------------- <br /> -------•-----------------------•--------------------•---------------------------------------­-- ----------------------------------------------------------•-----•-------------------------•-•----. .----- --------------- <br /> ------------ ---------------------------- --------------------------�----�----- ---------------------------------------------------------•--------------------------------•------------�--------------------------- <br /> FINAL INSPECTION -BY-----------.......... - ------------------------------ Date------------- r � ------------------------ --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street' 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California • Tracy, California <br /> ES-9-2M ; Revised W-2100 <br />