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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued ---- <br /> ell <br /> Aplica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This <br /> application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND CATION - ---------- ----------- ------ <br /> .6 ----620-001�------------------------------------------------- <br /> Owner's Name------ --- ---- - ------ - --------- ----- - --- -------------- ------------------------------------- -- Phon <br /> a-00/ ----/--.. <br /> Address---- ------------: --- --•-- ---------­---- <br /> -- -- <br /> Contractor's Name --------- ------- 1 ----------I----------------------------------------------------------------------------------------- <br /> Phone---.3------Z-4�"-'17 <br /> Installation will serve- Residence 00 D< Apartment H se ❑ Commercial E] Trailer Court El Motel El Other. El <br /> Number of living units: ---1-- Number of bedrooms _AZ Number of baths /--- Lot size --------------------- <br /> Water Supply: Public system 0 Community system F1 Private ld Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Nam 0 Clay Loam El Clay [j Adobg.W Hardpan E] <br /> Previous Application Made: Yes E] N 09 New Construction: YeA No E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public'sewer is available within 200 feet.) <br /> Septic T 'nk: Distance from nearest well-----------------Distance from foundation--------- ----------Material------------------------------------------------ <br /> No. of compartments- -------- -------.--Size----------------------- -------Liquid depth--------------------------Capacity-•-----------------` <br /> i d. <br /> DuDisposc5l RDistance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line_-------_-------- <br /> m <br /> N ber of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- <br /> Type of filter material-------------------------Depth of filter material----------------------.Total length--------_-------------------------------_- <br /> --------Distance fom.fouAdafion_,-1�. ..........Distance to nearest lotAirie—jr �j <br /> T 6 . "0 <br /> Sewe Pit: Distance to nearest well-/ ---------- <br /> Number of pits._/---------------Lining materi�ajC�__M� <br /> -----Dept h----- 0--------------i?,-f <br /> i�� . I <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------_-_----__.----_--------_-.- <br /> M Size: Diameter------------------ -------_ --------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-_-------._-.-----_----_-----_.__-____.-. <br /> ❑ <br /> uilding--,--------------------------------------- <br /> El Distance to nearest lot line--------- -----------------------------------------------P---------------------------------------- --------------------------------- <br /> Remodeling an repairing (describe):-----e <br /> ---------------- --y--- ------------------- ------------------------------------------- ... --------------------------------------------- --------------------------------------------------- ---- ----- <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, State laws, and rules and-regulations of the San Joaquin Local Health District. <br /> {Signed)----®r_,e_ --------------------------- ------------------------------------------------------- -----------{Owner and/,9roContracfor] <br /> ----------------------------------------------------------------------------------------- - <br /> ------ - <br /> By:------------- <br /> (Plotplan, showing size of lot, location of system in relation to wells, buildings, etc., can be plg��d on reverse ide). <br /> Remodeling a n repairing <br /> ..... ..... <br /> d Xl <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY$ D ATE- ----------------------------------- ------------------------------------------------ <br /> REVIEWED BY------------------------------- <br /> j -------------------------------------------------------------------------------- DATE <br /> ----------------------------------- <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------- ----------------------------------- i <br /> Alterations <br /> ATE-------- ------------------------------------ <br /> Alterations and/or recommendations:----------------------------------------------------------------------------------------------------------------------------I---------------------------------- <br /> - I <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------- <br /> ------------------------------ ----------I-------------------------------------------------------------------------------------------------------------------------------------------­------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------- ----------- ------------ --------------------------------------------------------------- <br /> ------------------------------------- ------- ---------------------------- - -------------------------------------------------------------------7------------------------------------------------------------------- <br /> FINAL INSPECTION Date /— -2 e"- <br /> ---------------------- ------------- ------------ -- -------­­-------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street .814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2iGO <br />