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ti <br /> ' <br /> V <br /> APPLICATION FOR SANITATION <br /> PERM[ Permit No. <br /> (Complete in Duplicate) S <br /> �+ � Date Issued <br /> V 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 /> JOB ADDRESS AND LOC T N,. ��/�Q n�' -- --- G .`�Jt /E� " <br /> Owner's Nam --- ------------- - •----------- . Phon —4_1-- -------- <br /> f ` ---- <br /> �j' !!! <br /> - ---------------- <br /> Owner's <br /> --- <br /> Address '- - ; - . ` Eat>iJ. `' ----------------------- <br /> -- --- ------------ <br /> Contractor's Name-- ------- ------------------------------------------------------------------------------------ac,_`_----�------------------•----•--- Phone----------------------------------- <br /> Installation will serve: Residence E] Apartment House E] Commercial [if' railer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -------- Number of bedrooms -------- Number aths ________ Lot size _ ____________ _ <br /> Water Supply: Public system ❑ Community system fl Private Depth to Water Table ________ ft� <br /> Character of soil to a depth of 3 feet: Sand P Gravel [j Sandy Loam Clay Loam E] Clay E] Adobe Hardpan E]Previous Application Made: Yes F] No New Construction: Yes LTJ No ❑ f <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: y <br /> (No septic tank or cesspool permitted if public s�wer is available within 200 feet 1 <br /> Septic ank: Distance from nearest well__s`�` 0 Distance from foundation______ ________.Material_-_. ______- ._r' '. <br /> No. of compartments ! �� Size Liquid de t� ---------Capacityy------ <br /> Dispos I Field: Distance from nearest well�//_T_.Distance from foundation Distance to nearest lot li e2__Q5____ __ <br /> Number of lines____________ ___ Length of each line___________ <br /> I 9 , Width of trench g € <br /> Type of filter materi .+ epth of filter material___________ _______Total length---------[J--_0_______________________ <br /> Seepage Pit: Distance to nearest well---------------------- from foundation-------------------.Distance to nearest loft line------------____ <br /> ❑ Number of pits----------------------Lining material.----------------------Size: Diameter------------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_________---______________---__-__-_El . <br /> Size: Diameter--------------------------------------Depth -- -------- ---------------Liquid Capacity "..gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------.__._________--___. <br /> ❑ Distance to nearest lot line----------------------------------------------- <br /> Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------........_..----------------------------•---------------- <br /> - ----------•-------------•----•-----------------------------•-------------•------------------------------- ---------------------------------- -------------------------------------------------------- <br /> A <br /> ------------­-- ..............•--•---------------------------------------------------------------------------------------------------- -----------••--------------------------•--------------- <br /> ---------------------------------------------------------------------------- ;� <br /> I hereby c ify that I have prepay d this application and that the work will be done in accordance with San Joaquin Count <br /> ordinances, St laws, and rut s an gulations of the San Joaquin Local Health District. <br /> (Signed) ---------------------------------------------------------(Owner and/or Contractor) <br /> By:------------------ -------------------------------------------------------------------------------------------------------(Title)-----------•-------------------------------------- ' = <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY--- ------------------------------------------------ ----------------------------------- DATE-_.tr�---------------------------------------------- <br /> REVIEWEDBY---------------------------- --- ---- - ------------------------------------------------ - - ----------------- DATE---- ----------------------•------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------�N--------------------------------------------- <br /> Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------i-�--------------------------------------------- <br /> -----------------------------------•----------------------------------------------- ---------------------------------------------------------------------------------------------------•------------------------------------- <br /> -----------------------------------------------------•----------------- -------------------------------------------------------------------•----------•-------------------------------------------------------------- <br /> ------ ------- - <br /> -------------- ---------------------------- -------------- <br /> ----------------------------------•-------- <br /> FINAL INSPECTION BY-------------U1?5 � Date _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Stree+ 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES--9----2M 8-51 Revised W-2100 <br />