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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <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 with County Ordinance No. 549. <br /> oo <br /> JOB ADDRESS AND 'LOCATION-------: _ _`. -. _____:_ <br /> Owner's Name---------rC_-l...,--X...-•-- Phone <br /> Address •-•- ------------------------------- <br /> ---- ----------------- <br /> --------------------------------------- <br /> -------- <br /> f <br /> Contractor's Name----- - --1-- -jj " i--u--Q-�'. �� rLdJf4 = Phone r✓ ------- <br /> Installation will serve: Residence ZApartment House ❑ Commercial ❑ .'Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __/__ Number of bedrooms .�Z Number of baths ___ _ Lot size ______Ll _f -------f-5-_a-------___ <br /> Water Supply: Public system `Community system ❑ Private ❑. Depth to Water Table -------- ft.. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ ; <br /> Previous Application Made: Yes ❑ No New Construction: Yes X No ❑ � i <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> � � <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i <br /> � 1 <br /> Septic Tank: Distance from nearest well_________________Distance from foundation__-_ __.Material____-±.,-_________--_________________________. II <br /> ❑ No. of compartments--------------------------Size---------------------------_-Liquid depth---------------------- --Capacity--------------•------- i <br /> Disposal Field: Distance from neare t wefl------------------Distance from foundation__ _ Distance to nearest lot I�e--------------- <br /> _. <br /> Number of lines____ -------- r_Length of each line_________ Width of trench_____ <br /> ff <br /> Type of filter material____ -_-Depth of filter material_____l_ ....Total length---___,l _____________ <br /> Seepage Pit: Distance to nearest well__--, ____=---------Distance from foundation--------------------Distance to nearest lot line_______-_______ <br /> ❑ y Number of pits----------------------Lining material-------------.---------Size: Diameter------------------------Dept h------------------------------- <br /> Cesspool: Distance from nearest well-------------------Distance from foundation--------------------Lining material-------------------------------------- v <br /> ❑ Size: Diameter--------------------------------------Depth------------------------------------------------------Liquid ,Capacity-----------'------.------.gals. <br /> Privy: Distance from nearest well---------------------- a---____-------__________Distance from nearest building----_.________________-_-__--____________- <br /> ❑ Distance to nearest.lot line '---------------------------------------------------- -------------------------•---------------------------------- <br /> Remodelingand/or repairing (describe):-------------------------------------------------------------------------------------------------------------------I----------------- -------•-------------- <br /> ------•------------------------------ --------- --------------•-----------------•----------------- <br /> ------------------------ -------------------------------------------------------------------------- -----------------•----------------------------------- <br /> 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 <br /> and regulations of the San Joaquin Local Health District. <br /> -----Y-- G �._'' 1 C_- - 1.-: rG�/'�•G1----- , <br /> (Signed) a •. �( �C1r.� <br /> F ���- --- •-. ________________ caner and/or Contractor) <br /> By:-----�;_ - •.=.... = - ------ - ----------------------------------------------------------------(Title)-------- -��'--------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on rev se side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - DATE----- 141 <br /> REVIEWEDBY ----------------------------------- -------------------------------------------------------------------------------- DATE------------------ <br /> BUILDING PERMIT ISSUED--------------------------------------------------------------------•--------------------------------- DATE <br /> ---- <br /> Alterations and/cr recommendations:--------------------------------------- ------ --------------------------------------------------------------------- ---------•-------------------- <br /> ---------------------------------­------------------------------------------------------------------ ---- --- -- ------ ----------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:_ ------ -- r � -- --------- Date--- --------------------------7�----------------------------------------- <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 8-51 Revised W-2100 <br />