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Permit No. S^ <br /> APPLICATION FOR SANITATION PERMIT -------•------ <br /> (Complete in Duplicate) �J l- <br /> Date Issued __/___ <br /> x Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> fThis application is made in compliance with County Ordinance No. 549. <br /> JOBADDRESS AND LOC ATION------- D ------ -------------------------------------------------------------- -------------------- <br /> Owner's Name----------------------- -------- -----------'----------- --------------- Phone------------------------------------ <br /> 11161 <br /> :-------------•------------- --------------------------------------------------------------------------- <br /> Address-------------------------------• ---�----------- <br /> Contractor's Name---- --------• `` ----------------------------------------------------------------------------------------------------------------------------------------------------- --------------- Phone----------------------------------- <br /> Installation will serve: ,Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ MoteX Other ❑ <br /> Number of living units:._.ice-Number of bedrooms 7Z—Number of baths _I----- Lot size ------- __x - ----------------------- <br /> Water Supply: Public;system ommunity system '❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam p.rCZy ❑ Adobe ❑ Hardpan ❑ ' <br /> Previous Application Made,: Yes ff' No 0 Now Construction: Yes Eii_ Qo�❑ <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__�_nP Disfancefrom foundation---tD____------.Materiak------- <br /> L;(1'7► <br /> i No. of compartments-------- ,�-- -- Size. }` ��----------Liquid depth--------4--------------Capacity <br /> Disposal Field: ,Distance from nearest well___1N cm Distance from founda1ion_--_1_jD-k"____Distance to nearest lot liner __ , <br /> Number of lines--------------�------------Length of each line------- <br /> �e_ -- -------Width of trench-------- -- ------------- <br /> / Type of filter material---S'_rkAW __Depth of filter material---1_1_-_. ___Total length------- <br /> (I , <br /> _---__r " <br /> Seepage Pita, 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-----------------Distance from foundation--------------------Lining material__________-____________________-____. <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well -----------`�_�""`---4=-- ==---=Distance from 'noa"rest-building _____ _ _­ <br /> ---------- - <br /> ❑ Distance to nearest lot line------------------------------------------------• --------------- ----------------------------------------------------------------------- <br /> r <br /> �' ---`---- - <br /> Remodeiin9 and/or repairing � <br /> � - ---° ---------------------------- <br /> -------------- <br /> -- - ------------------------= <br /> -- <br /> r- - =--- ------------------- <br /> --------------- ---- ----- ------ - ---- <br /> I hereby certify that I have prepared this application and that the work will be done <br /> in accordance with San Joaquin Coun+y <br /> ordinances, St fe laws, and I s and' r gula o f-the San Joaquin Local Health District. <br /> (Signed) _ -------------------------- ------------ - --------------------- ---------------------------------------------------------- -----------`----------------(Owner and/or Contractor) <br /> By------------------------------- ----------------------------------------------------------------------------------------------------(Tifle)------------------ -------------------------------------------- <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 �} I <br /> APPLICATIONACCEPTED BY--------------- ---------- ---------------------------------------------------- DATE......... 1- --------------------------------- <br /> REVIEREVIEWED <br /> WED BY----------------------------------------------------------------------------------------------------------------------------- DATE---------------------------------___-------------------- <br /> BUILDINGPERMIT ISSUED-------------- --------------------------------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations:--------- ---------------------------------- ------------------------------------------------------------------------------------------------------------ <br /> 1 ----------------------------------------------------------- ----------------------------------------------------------------------- <br /> -----------------------------------------------------------•--------•---------------------------------------- ---------- <br /> FINAL INSPECTION BY:----- --- �--- -------------- -------------------- Date-----------c=J'---------t---- ---------- ------------- <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California i Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 <br />