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n <br /> APPLICATION FOR SANITATION PERMIT Permit No. _____ <br /> (Complete in Duplicate) <br /> Data Issued ___: <br /> Applica4ion is hereby made to the San Joaquin Local Health District for a p rmit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance . 5 <br /> JOB ADDRESS AND LOCATION_____!/_____ _ ___._._ I <br /> Owner's Name----- '_.. ___..-•-------... -----.----- - --------------- Phone _ <br /> ------- <br /> Address---------11• --- --------- ------ --------�----- --------------------------------------------------------------•- ----= <br /> -------------------------- <br /> Contractor's Name--- ---•----------•-------- •---- -- � ---------------------------------------------_ Phone----••--•--•----•-•--•-- - <br /> Installation will serve: `Residence r Ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> _ <br /> Number of living units:__/-.-. Number of bedrooms __ f baths ---l__ Lot size _ do___ t-5-_______________ <br /> Number o <br /> f <br /> Water Supply: Public systerh,`[t`Community system ❑ Private 2f--IDepth to Water TableIV-14- ft. <br /> Character of soil to a depth of.3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 4---�pan ❑ <br /> Previous Application Made: Yes ❑ No 6--ITew 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 /> -f_..._.Matia�_ +�-- -----. <br /> Septic Tank: Distance from nearest well__� _. Distance from foundation__. <br /> [ No. of compartments-----_0-----------.Size---+�_..�- � .Liquid dept .-----------Capacity__�W!P-------.- <br /> Disposal Field: Distance from nearest well-e-- Distance from fdundation__/ '-_Distance to nearest lot line____.._. <br /> EL_— Nurn be' of lines_.____:___._ __ ___ --- Length of each line--------7..Q__!-----------Width of trench ------------------------- <br /> Type or filter material - :Depth of filter material_____ ------------ otal len th.__3P--------------------------------- <br /> Seepage <br /> --------- ---- ----- <br /> Seepage Pit: Distance to nearest;well_-Td---__:-----Distance rom f6undation-..-4d__*___.Distance to nearest lot le__%.1_7------ <br /> Number of-pits------- __Lining,material- __.Size: Diameter__ � De th__ ____________ <br /> i t . _ <br /> � <br /> Cesspool: Distance-from,nearest well_________________Distance from foundation_ Lining material-_-.-------------------------------- <br /> El Size: Diameter:----------------------------------Deth--------------- _---------- ----------------------Li uid Capacity ..gals. <br /> Privy: Distance-from nearest well------------------------------------------------------Distance from nearest building------------------------------------------ <br /> -Distance <br /> _ __________ __________________________.Distance to nearest lot.line----"---`=`----------, :. .. - --- _ -------------------------- <br /> Remodeling <br /> -- -------------Remodeling and/or repairing (describe):------------------------ <br /> -------------_= <br /> .. <br /> ------ .----- <br /> _________________________________________________________________________I-____________________-;_____-_______________________-__________.______..__.....-____.___...______________________________________-. __ -____.__ <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, S laws,` nd rule dreg ations i f the San Joaquin Local Health District, i <br /> _. :. <br /> (Signed)---• -:----- ----------------------------------=- -- ---------- (Owner and/or Contractor) <br /> BY: - --------•--------- -------------=---------- (Title). ---------------------------------------`--------- i <br /> (Plot plan, showing size of Iot, location.of,system in.relation to-wells, buildings, etc.; can be placed on reverse side). <br /> _ FOR DEPARTMENT.USE ONLY <br /> APPLICATION ACCEPTED BY-- -------- ----• --- ---•--------•-•----- --------------- D11__: ---------------------------------- <br /> REVIEWED BY------------------------- `== - DATE <br /> BUILDING PERMIT ISSUED-----------------------------------------------��`--------------=-------------------------------- DATE---------------------- � ��----------- <br /> Alterations and/or recommendations: =------------------------- ••---•-•----------------------------------------------------....... --------- -------------:--------- <br /> -- --------------------------- ---------------•-------- <br /> -------------------•---------------------------------•------------•- ----------------------------------•------••-•--•-_----•--=--------------------------------.-.---•-•-----•-----• ---------------­­­------------------- <br /> ---------------------------------------------------------------- ------------ ------ ----- -- ----------------------------- _.-- --------------------------------------------- ---- ------------------------------- <br /> -----------------------------------------------------------------=-------------------------- -- ------------------ ---- ---- -------------------- ----------- <br /> FINAL INSPECTION BY:------------- Date--=----------------;f.. = =. ►.----------------------------------------- <br /> SAN <br /> ='SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300.Wosf Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />