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APPLICATION FOR SANITATION PERMIT Permit No. ........... <br /> (complete in Duplicate) <br /> Date Issued <br /> A <br /> This <br /> hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> 's application <br /> cation ,s made in compliance with County Ordinance N 5 9 <br /> G / <br /> (/ -;� _ "Or2 ---------------- <br /> JOB ADDRESS AND LOCATION____ -— ------ ------------------------- -------------------------- <br /> I - <br /> Owner'sV' Name- -------- --- ----------------- -------- ---------------------------- Phone-------------------------------•---- <br /> Address----------------- - ---------- ----- -------------------------------------------------------------------------------------------- <br /> ---------- ----------- Phone*__.6__=Z_6_/ <br /> .Contractor's Name----- <br /> Installation will serve: Residence Z_, _6zartment House E] Commercial E] Trailer Court E] Motel F] Other Ej <br /> Number of livi rooms _9 ...... ------ ----------------- ----------- <br /> fig units:----/--- Number of bed Number of baths _/----- Lot <br /> Water Supply: Public system"��ommunity system El Private 0 Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand 0 Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 6­151—ajean E] <br /> .E1 13 El <br /> I <br /> Previo6s Application Made: Yes El No []�w Construction: Yes E] No Eg, <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank;. Distance from nearest well_________________Distance from foundation--------------------Material-------------------------------------- ---------- <br /> No. of compartments.-------------------------Size-----•-•-------------------_Liquid depth----------- ----- --------Capacity------------------- <br /> Distance from "nearest we€l------------------Distance from foundation-----------------.-Distance to nearest lot line________.___..._. <br /> Disp sal Field: <br /> ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of french--------___--------------------- <br /> Type of filter materiaJ-------------------------Depth of filter material-----------------------Total length___-"_-_--____---_--_________-____.__._ <br /> Seepage <br /> ength------------------------------------------ <br /> Seepage Pit: , Distance to nearest well_'-�-- ---�'istance from foundation---. _,p_"'--..Distance to nearest lot <br /> umber of pits._.___.--____--____Lining material--- _Size: Diameter___.,„_-__---.--_ ----------- <br /> _/------------ .3-3------ -----Depth__..?_.V........... <br /> Cesspool- Distance from nearest well-------------------Distance from foundation-------------------Lining material__.__-_--__-------__-____________- <br /> ❑ Size:sQiarrieter___ _ -- ----------Depth------—--------- ------- ----------'_.gals-'- -'- -.4 <br /> Privy:; Distance from nearest well-------------------------------------------------Distance from nearest building_._._______________--__________-._---_. <br /> - <br /> © istance-to <br /> uilding------------------------------------------ <br /> 'isfance-to nearest-lot-line-1--­-Irt��- ------ntv­'__ <br /> -------------------------------- <br /> Remodeling and/or repairing-(describe)____________________________ i 1' <br /> ----------------------!---------------------------------------------------------------------------I--------------------1-1------------------I-------------- ------------------------------------------------- <br /> I __�;"1 7:--------------------------------------------------------- <br /> ---------- ------------------ -----------*------------------------------------------------------------------------------ ----- <br /> --------------------------------------------------------------- ----------------------------_.1.1------------------ ------------1--------------------------------------------------------------------------------- <br /> I hereby certifythaf I ha4 prepared his application and that thet work will be done in accordance with San Joaquin County <br /> ord;nAces, S 'laws, n.d rule.)and"reg1tu1a+ions of the San Joaquin Vocal Health District. <br /> i Ll <br /> (Signed)_ -- --- --------- ---------- ---Con <br /> --- ------- <br /> --- -- -- tractor) <br /> By:-..... ........ _uT------------------------ --------------------------------- - -- ---------------------------------- <br /> (Plot plan, showing size of location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> �17 <br /> nd rule <br /> FOR DEPARTMENT USE ONLY <br /> APPLILATION XCCIEPTED,BDATE ---------------------------------------------------- <br /> ------------------------------------------------------------------------------------ <br /> REVIE� ED BY------------------------------------------------I------------------ ---------- ---------------------------------------------- DATE__-nV--------------------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------ ----------------------------------------------- <br /> Altereltions-a n44or_r_ePQm mPnJ%ifkcLn ------ ----------­------ -­ -------•-_------------- -------7- ---------------------------- <br /> ----------------------------------------------------------------------------- ------------------------------------------------------­-- -­------------------------­­­------------------------------------------ <br /> ----------------------- -------------------------------- ------------- ----------------------------------------- ------------------------------------------------------ -------------------------------- ...... <br /> --------------;i--------------------------------------------------------------------------------------------- ----------------------- -------------------------------- -------------------------------- <br /> ------------------- <br /> ------------------------------ ------- ...... -------------------------------------------------------------------------------------------------I------- ----------------------- --------------------------------------- <br /> FINAL-INSPECTION ------------------ :------­------------- Date------------------------------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Streof 300 West OA Street 132 Sycamore Street 814 North "C" Sfroof <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> -CS-9-2M Revised W-2100 <br />