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\�1n APPLICATION FOR SANITATION PERMIT Permit No. <br /> n" <br /> ((;omplete in Duplicate) 3 <br /> Date Issued <br /> A plica-lion 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 Ordina e No. 549. <br /> JOB ADDRESS AND LOCATION....__�_15e <br /> f <br /> -------- -------- - - - <br /> Owner's Name--------------- ------------ .1�-'Ql - Phone <br /> Address....... ---------------_ -------------------------------------------------------------...._.._...---------------------•------- <br /> Contractor's Name------ ------------••-- ---- ----- ---------------------------------------- -------------------•• - •-•- •--••-._. Phone----------------------------------- <br /> Installation will serve: Residence-2t",,,_Apartment House ❑�Coommmercial [-] Trailer Court E] Motel ElOther El <br /> Number of living units: _�-`-,Number of bedrooms __a Number of baths -1____ Lot size ._ __ X .. - ________________ <br /> Water Supply: Public system ❑ Community system ❑- Private` Depth-to Water Table <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AclobeAA Hardpan ❑ <br /> Previous Application Made: Yes ❑ No%;a, _New Construction: Yes'5j�,No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: i <br /> (No septic tank`or cesspool permitted if public sewer is available within 200 feet.) ' <br /> Se tic Tank: Distance from nearest well__ _ Distance from f undatio !_�__ "_:.Material____ �1L.___-_' <br /> No. of compartments._____. _ -_______Size----- X-1 quicl depth-------- <br /> ----_.Capacity_. <br /> Disposal Field: Distance from nearest well_._,_5r_yDistance from foundation___. -Distance to nearest [of line-----k—CM.,._-_._ <br /> s. <br /> Number of lines____________�______.._.!_ Length of each line____,__._____ Width of trench---------2,4(________________ <br /> Type of filter material.. _ ._Depth of filter maferial____�- _---�_--__-_Total length__ ---- ?,� _____________________ <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----------------- from foundation-------------:......Lining material___-______________________________- y <br /> ❑ Size: Diameter--------------------------------------Depth---------------------•-------------------- --------Liquid Capacity --------------------------gals. [� <br /> Privy: Distance from nearest well---------------------------------------- from nearest building.__.__.___.__._-______-.____._____-____. <br /> ❑ Distance to nearest lot line--'-----------------------------------------------------=--=--------------------------------------------------- <br /> , <br /> Remodeling and/or repairing (describe):------- -------------- ---------------------------------------•-----------••------------ -------.......• ••----------------------------------•-----•-- <br /> --------------------------------------------------------------------------------------------------------------------------.----•-------..-------------------.---------------------------------------------------------------- <br /> S <br /> __ _ _ _____________________________ _________________________________________________________________________________________________________________________»-...____-_--__________________________._____._._ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, ayAruIesjnd regulations of the San Joaquin Local Health District. O <br /> t <br /> (Signed --d&' A4wo-a�_-------- ---------------------- ----------------------------------------- ------- ----------- ------{Owner and/or Contractor) <br /> • (Title)_ <br /> t Z <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 - f <br /> APPLICATION ACCEPTED BY - - DATE ---------------------------------' �� <br /> REVIEWED BY-------------------- <br /> ------------------------- ------------------------------------------------ - --- . ..... DATE----- -------------•-•------ <br /> BUILDINGPERMIT ISSUED------------------------------------------------ .__.- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations:------------------------------------------------ ----------------------•--...-----..--.....------••----....----------------------------------------•----- <br /> ------------------------------------------------------- <br /> --•-------------------------•-----------------------------------------------------•------ ----------------------------------------------------------------------=-----------.------------------------------------------ <br /> ----------------------------------------------------------------------------.--•----------.----------------------••------ ------------------------•------•-------•-----------•----------------------- ------------------ <br /> 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" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-•-2M : Revised W-2100 <br />