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APPLICATION FOR SANITATION PERMIT Permit No. ____________________ <br /> (Complete in Duplicate) <br /> F { 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 Ordinanc No. 54 <br /> JOB ADDRESS AND LOCATION------r�-------� ---- --- - �'&'t Z. <br /> -��� ='y ` <br /> --- - ----- <br /> Owner's Name------------------------- �/v------- ------ _ ft -�-- --------- Phone <br /> Address------------------------------- ------------: ------------------------------------------ ----- ---------------- <br /> � � <br /> -- <br /> Contractor's Name 1 / - �.tr- - -o*� �'_�'r� � Phone -- <br /> Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _ -__ Number of bedrooms Number of batlis /- Lot size ------ _ ___ _ __ __________________ <br /> Water Supply: Public system ❑ Community system ❑ Private [j-`Depth to Water Tableft. <br /> Character of soil to a depth of 3 feet: Sand [ /Gravel ❑ Sandy Lo;9N, <br /> ay Loam E] Clay E] Adobe[ Hardpan E]Previous Application Made: Yes [jNod New Construction: Yes ❑ <br /> p 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 /> - <br /> ❑/rj No. of compartments----- Size Liquid depth Capacity <br /> Disposal Fielcl7 Distance from nearesT well_A___.-----Distance from foundation__/'4-____-___-Distance to nearest lot line-/4 ------ <br /> E/-' Number of lines____ ,� r' Y_____ Length of each line__�a______,_______-Width of trench____ ____________________________ <br /> Type of filter materi _ <br /> al ;A� <__Depth of filter material__._�....-____Total length______�_'_V- __ <br /> _____ ______________-_ <br /> Seepage Pit: _Distance to nearest well d-__________Distance frgm foundation_ ___.Distance to nearest lot line___...0.------ '�• <br /> Number of pits___ ,____Lining m aerial--4574� !-Size: Diameter_____------------Depth______s _ __________ O <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material._________--________________________-. <br /> Size: Diameter------------------ ---------_-------De th------------------__ }-----------------------Liquid Capacity----------------------------gals. Wj <br /> Privy: Distance from nearest well------------------------------------------_-------Distance from nearest building________________________________ <br /> ❑ Distance to nearest lot line------------------ --- -- ---------------------- ---------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe--------------- _' �---- -� -�- --- -_�'tL -x7� _, <br /> - ---------- <br /> -----------------------------------------------------------------------f ----------------- ---------------------------------------------------------------•-----------------------------------------------------------------------------------------------•--------- ------------------------------ --------1----------------------------- <br /> -------------------­--------------------------------------------.__.---------------------------'---------------------------------------------------------------- ---------------------------------------------------------- <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;. alth District. <br /> -_---_ <br /> __-- - - - - _ F - 9------------ <br /> ------(Ownof and or_ <br /> Contractor)3-(Title) C ��'BY: ---- 7 Vit. <br /> (Plot <br /> 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 BYIV/ '-- r DATE------- <br /> REVIEWEDBY------------------------------------ � �- ---------------------------------- DATE------- -- --- ----------------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------------- ------------------- <br /> Alterations and/or recommendations:---------=--------------- ------------------------------------------------------_--_-------------------------------------------- <br /> ----------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------- ------------------------------------------------------------- ------------------------------------------------------- -------- ----------------------------------•-------- <br /> FINAL INSPECTION BY---------------------- ------ - - Date-----------------__ <br /> ~ ` <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 9-51 Revised W-2104 <br />