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f <br /> ' APPLICATION FOR SANITATION PERMIT -Permit No: <br /> (Complete in Duplicate) <br /> 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 Ordin nce N . 549. <br /> ------ <br /> JOB ADDRESS i [X LOCATION Y R r <br /> Owner's Name a Phone__ j <br /> ---- - - ------- - -------------- <br /> Address �i! _ ... `-- -- --- --------------------- -----------------------------------------------------------------------•---------------------------------------------------- <br /> Contractor's Name----- ------- --------- -- ------------------------ ------------------------------------------------------------------------------ Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___�__ Number of bedrooms -------- Number of baths ________ Lot size ___________________________________________________________ <br /> Water Supply: Public system 0 Community system ❑ Private N( Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel I] Sandy Loam Clay Loam E] Clay ❑ Adobe/Hardpan F] <br /> Previous Application Made: Yes E] No ( New Construction: Yes ;No ❑ <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---------:-------- quid�de th_ __Capacity------------------------�X <br /> i <br /> Disposal Field: Distance from nearest well------------------ from foundation--------------------Distance to nearest lot line-_______________ <br /> ❑ Number of lines_--#------------------------------Length of each line------------------------------Width of trench------------------------------------------------------------ <br /> Type of filter material-------------------------Depth of filter material----------------------Total length--------------_-----.--------------------_ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------_-----:Distance to nearest lot line______:__________ x <br /> ❑ Number of pits------- -----------Lining material-----------------------Size: Diameter__-----------_ Dept ----._-------------- ------ <br /> ____ ___ Lining material_ _ ___ <br /> I 11 I� _ <br /> Cesspool: y1�C Distance from nearest well_��__T_Distance from f undation_____ ____/_�____ ___________. <br /> DSize: Diameter-----a---XZ------------- ---Depth---- ------------------------------------Liquid Capacity 1 L 5als. <br /> Privy: Distance from nearest well--------------------------------------------------Distance from nearest building--------------------------------.__________- <br /> ❑ Distance to nearest lot line------------------------------------------------------------ <br /> and/or repairing (describe):--------------------------------------------------------------------------------------------------------------•-•--•-------------------- <br /> ------------------------------------------------------------------I-------------------------------------------------------------------•--------------------------------------------------------- <br /> -------------------------- <br /> I <br /> f <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)----- �, ------ auuv--- �-'-"`------------;----------------------------------------=.-----------------------------------------(Owner and/or Contractor) <br /> BY:-- C.a ?art lA --------------------------------------------------------------(Title)---------------------------------------------------------------- <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 <br /> APPLICATION ACCEPTED BY---- ..--------- . ---- -------------------------------- -- = DATE <br /> REVIEWED BY-------------------------------------- <br /> --• ----------­1------------------------------------------------------------ DATE------------ --------------------------------------- <br /> BUILDINGPERMIT ISSUED--------------- `--- --------------------------------------------------------------------------------- DATE----------------- - - <br /> Alterationsand/or recommendations_ -------------_____------------------------------------------------------------------------------------------------------------------------------------------- <br /> ,a <br /> [#. <br /> ------- ---- ------ --- ?'�' ('' rl w •�Ci 1� '�''--------)------- <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 I <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9---2M 8-51 Revised W-2100 <br />