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APPLICATION FOR SANITATION PERMIT Permit No. <br /> 5 'tib (Complete in Duplicate) Date Issued/V <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 Ordinance No. 549 <br /> JOB ADDRESS AND LOCATION.------------- ------ --------------- <br /> Owner's Name--------- _�_ __4,------ -- ---------------- --- ------ —- -- - - - - ------ ---------- !, Phone------------------------------------ <br /> Address....._...... ...... Aj- .... <br /> %,-- __- - - --------------------0------------------------------------------------------------------------------------- <br /> Contractor's Name-------------------------Aat___�_ _ ----------------------------------------------------------------------------------- Phone----•----------------------------- <br /> Installation will serve: Residenceaow Kpatmerif House E] Commercial E] Trailer Court [] Motel [:] Other E] <br /> Number of living units: ---)--- Number of bedrooms __.�--- Number of baths Lot size ------ --------- <br /> Wafer Supply: Public system El Co I mmunify system C] PrivateAerfh to Wafer Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand D Gravel E] Sandy Loam lay Loam E] Clay E] Adobe E] Hardpan E] <br /> 14, <br /> Previous Application Made. Yes 0 No �ew Construction: YesE�-�o El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if pysbliC e is available within 200 feet.) <br /> I <br /> Septic Tank: Distance from nearest well- - fro f n <br /> -------------- isiance, r ra ou_dation-----)_0--------Materisill-_______S _------------- ---- <br /> Ix No, of compartments----------)--—--------Size---�gx_7x__�$------Liquid depth----__ _. -_____Capacity___ _ -- ql <br /> Disposal <br /> epth----- <br /> Disposal Field: Distance from nearest weli/"t.---t4e(rice from foundation----/0 Dista nce to nearest lot I' e <br /> 717------------ <br /> e s Width of ire ------------------- <br /> T <br /> ------------------ <br /> X, Number of lin ------------- ------ -------Length of each line---------- _41------------ rich------ <br /> Seepage Pit: Type of filter material---A---2�,___"_ ._Depfh of filter maferial____1_')-—--------Total length-----------4-D----------- <br /> Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__-__-___-------. <br /> ❑ <br /> ine----------------- <br /> 0 Number of pits----------------------Lining material---------------- ------Size: Diameter-----------------------Depth----------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from founclafion--------------------Lining material------_______________________________. <br /> El Size: Diameter----------------- --------------------Depth--------•------------------------- ----------------Liquid Capacity---------------------- ----gals. <br /> Privy: Distance from nearest welt____ _______________________._-._Distance from nearest building_______._______--_------____-_______-____. t <br /> ❑ Distance <br /> uilding------------------------------------------ <br /> Distance to nearest lot line.----- ------------- ----------------------------------------------------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe):-------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------I------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------1------------------------------------------------------------- - <br /> -------------------------------- <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 Health District. <br /> (Signed -----------------------------------------------------------------------------------------(Owner and/or Contractor <br /> By:--------_-----_--_- -------------------------------------------------------------------------------------------------------Tale --------------------------------------------------------------- <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 /> ------------------- <br /> REVIEWEDBY--------------------------------------------------------------------------- --------------------------------------------- DATE----------------------- <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------- ----------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations:-------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------__--------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------- ------------------ ------------------------------------------------------------­ <br /> ---------------------------------I....I---- --------------------------------------------------------------I-----------------------------------------------------------------------I—- <br /> --------------------------------------- <br /> ---------------------------------------------------I--------------------- -------------------------------------- --------------------------------------------- ---------------------------------------------- ---------------- <br /> AWFINAL 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 8-51 Revised W-2100 <br />