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1 APPLICATION FOR SANITATION PERMIT Permit No. <br /> '• (Complete in Duplicate) .3f S <br /> Date Issued ----- --- --==------ <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. <br /> t This application is made in compliance with County Or finance No. 549.. <br /> '0 <br /> JOB ADDRESS AND LOCATION__ --C--- "41"'a� l/y <br /> Owner's Name �F:�-•t --- - " ---------------------- Phone_ (�t_01'- ------------- <br /> Address-------•------------------ <br /> Contractor's Name----------- <br /> ----------- Phone----------------- <br /> -------------------------------------------------------------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Comm.ercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size <br /> ---------------------- <br /> Wafer 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.E] Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ I No ❑ New Construction: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> F <br /> a (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 /> --_-----__-------__-----____--.._-_- <br /> ❑ No. of compartments-------------------------Size--------------------------------Liquid depth--------------------------Capacity--------- <br /> Disposal <br /> -- -Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line.__---______--_. <br /> ❑ Number of lines-`--------------------------------Length of each line-----------------------------.Width of french----------------------____ <br /> Type of filter material-------------------------Depth of filter material----------------------- length------------------------- <br /> ----------------- i <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation---------.----------Distance to nearest lot line_---- ____----. <br /> ❑ Number of pits---!------------------Lining material-----------------------Size. Diameter------------------------Depth------------------------------ <br /> I <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---_--_-------__-_.Lining material---_--__----_____---_____ <br /> ----- <br /> ❑ Size: Diameter--'-�-- --------•-------------------Depth--•------------------------ -------------- -----Li uid Ca Capacity p tY---------------------- gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building <br /> ❑ Distance fo nearest lot line <br /> Remodeling and/or repairing (describe):----_b`lf--- _- -__ <br /> - - -- -- ------ -----"t <br /> I ----------- ------------ <br /> --------- <br /> --------------------------------------------------------------------•------------------------ ------------ <br /> I hereby cerfify 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) ��F � --- ------------------- (Owner and/or CAntractor <br /> B (Title � } <br /> Y• -------------------- ----------------------------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relafion to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------_E---- --- --- - - ---- - -------------------- DATE-- _-- <br /> ----------------------------------------------------- <br /> REVIEWED BY------------- DATi - <br /> �• ------------------------ <br /> UILDING PERMIT ISSUED--------- DAT <br /> ------------------------------------------- - <br /> teratioras and/or recommendations----------------_ <br /> -----------=--------------------------------------------------------------------------------------------------------------------------------- <br /> ye --------�eA------- -------�� :,r------------------------------------------------------------------------------- <br /> ----------------------------------------------------- <br /> ---------------- --- - --- <br /> Y�'-'� -----------C-r/y�r�--�------ . --------- 66"_4 ,- <br /> --------- ----- ----------------------------------------- <br /> _. <br /> ---- - ------------- <br /> FINAL INSPECTION BY---------------------__ <br /> ------- Date----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> 130 South American Street + <br /> 0 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California ! Lodi, California Manteca, California Tracy, California } <br /> f <br /> ES-9-2M 8-51 Revised W-2100 <br />