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APPLICATION FOR SANITATION PERMIT Permit No. .. � ` .. <br /> p- (Complete in Duplicate) <br /> Date issued <br /> 01-7 -r 0�,r) --37 <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 yrith County Ordinance N . 549. F <br /> JOB ADDRESS AND OC ON -- ----------4 ---------------•----- !_ --•----------------------- <br /> Owner's Na --- --- ----- ------- -•--- --- Pho LC------------- <br /> Address.-/W-- ---f .._ - ------- - �----• .`�' <br /> Contractor's Name----------- ---•---- •-----.---•- --------•--------------------------------------- -------- ------------------------------------ -------- Phone---------L'" - <br /> Installation will serve: Residence.Qf Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __.(-___ Number of bedrooms 2---- Number of baths __1_-_ Lot size ------------------------------------------------------------ <br /> Water Supply: Public system E] Community system ❑ Private X Depth to Water Table___ ft. <br /> 1, <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 14 Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ r4c) <br /> Previous Application Made: Yes ❑ No [ 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 /> i <br /> Septic Tank: Distance from nearest well--- Distance Jr�om fS�ncl, ion______ _D.__-_.M tejial__yj_._ . ____- _ _ ________ <br /> No. of compartments--------z`-`—-----------Size----�_�e�_,�i__��._�iquid depth__._�__.-_�__---::-Capacity__1-� ���} <br /> Disposal Field: Distance from nearest well.....5— Distance from foundation __ <br /> p ----- - �:��`___.Distance to nearest of I• g----------------- <br /> or , <br /> Number lines-_________ en th of each line--------- - __.Width of french-,. ------------------- <br /> f/ 9 <br /> Type of filter material____ �e th of filter material--_ ___.__Total len � --------------------------- <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--------------------------------------1------- -Liquid Capacity- --------------------------gals. <br /> Privy: Distance from nearest well___�"_____"____::_____'________________'Distance from nearesr building---------------_.-______---___T...__ lk%%I <br /> ❑ Distance to nearest lot line-------------------------------------------------------------------=---------------------------------------------------------------- --- <br /> near" <br /> k <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 /> - <br /> ordinances, St to laws and rules and regulatio s of the San Joaquin Local Health District. <br /> (Signed) ------------------------------------------------------------------- ----------------------(Owner and/or Contractor <br /> By:---------------------------------------------------------------------------------------------------------------------------- (Ti+le) <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- = --- ••----------------------- DATE r <br /> --- <br /> REVIEWEDBY---------------------------------------------------- ------------------------- ------------------------------------------- DATE--------------------- <br /> BUILDINGPERMIT ISSUED-------------- f--------------------------------------------------------------------------•----------- DATE------------ <br /> Alterations and/or recommenda+ions-----------=--.------------------------ - -------------------------------------------------------------•----------------•------------------ <br /> I <br /> -- -------------------------- <br /> ------•-•-------------------------------- ------- ---------------------- ------•-------------------------------­---------------- ------ - ------ - --------- --------- -------- <br /> FINAL INSPECTIO -- ------ -------------------------------------- - --- -------- Date------- ` <br /> fr - -------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 1O-52 Revised W-2100 <br />