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APPLICATION FOR SANITATION PERMIT Permit No. .--2-_7- _ _ <br /> (Complete in Duplicate) �- <br /> Date Issued <br /> f oC—®G�p <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descri ed. <br /> This..-aa�p``ppl�lication is made in compliance with County O%n�Nci,.t. <br /> 49.,: .;DDRES NON. C� e�fft// <br /> _ ____ ___________^___5-- .....-_ <br /> r� -- <br /> Owner's Name------•=�---=-•- -'----•-- - ------------------•-•------------------------ - --------------------------------------- Phone----5�-- ----- ---Lq—-- <br /> Address--------- & ----- a--�. ----------------------------------------------------------- <br /> s <br /> Contractor's Name---------------- --------•---- --------------------------------------------------------------------------------------- Phone-------------------------------- <br /> A <br /> Installation will serve: Residence Apartment House ❑ Commercial F] Trailer Court ❑ Motel E] Other ❑ <br /> 5 Number of living units: .--)---_ Number of bedrooms __ __ Number of baths __r/____ Lot size --------------------- <br /> Water <br /> __________________Water Supply: Public system ❑ Community system ❑ Private ' Depth to Water Table -------- ft. <br /> "} <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes;M 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---Ow---Distance from foundation-------__U____-Material----- _______- <br /> No. of compartments_______- _________Size---� _e ___ ___Liquid depth_______----------Capacity______ _ � ' <br /> /91 <br /> Disposal Field: Distance from nearest well__��__�___.Distance from foundation_____/Q__1_____-Distance to nearest lot line___ p__�. J <br /> Number of lines-----------IF---__ __ __ Length of each line-_-___- - -_----_.Width of trench_____ _-`�_________________ <br /> Type of filter mate ria l_�_�i�= __!�"Ggepth of filter material___1__�______________Total length-----------4.'�__-P---__-_ .-____._-_ <br /> Seepage Pit: Distance to nearest welt----------------------Distance from foundation--------------------Distance to nearest lot line--_----_.___----. <br /> ❑ Number of pits----------------------Lining material---------------------.Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------- <br /> Diameter--------------------------------------Deth------------------------ - ---_Li Liquid Capacity -__gals. <br /> Privy: Mstarice fiom`n1earest well_________________________________________________Distance from nearest building_________._______________"-�_ —" <br /> ❑ Distance to nearest lot line-----------=------------------------------------------------------------------------------------------------------------------- ---- <br /> i , 1 <br /> Remodeling and/or repairing (describe):------------------- .. .... -----------------------------------------------•------------------------------------------------•-------- <br /> II <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, aw and rule /and reg ations of the San Joaquin Local Health District. <br /> 2�61 - <br /> (Signed)--- A - ---=-- ---------------------------------------------------------------------------- ---------------- (Owner and/or Contractor <br /> By:----- l --(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 /> r APPLICATION ACCEPTED BY-------' 1 >' -- DATE---- a ` <br /> [/ ✓ <br /> REVIEWED $Y--------------------- -------------------- -- ------------------------------------------------ DATE---- -----------...-------------------------------- - <br /> --------- - - ---- - <br /> BUILDING PERMIT ISSUED--------------------------- --------------------------------------------------------- I)ATE----------------------------------------------------- <br /> Alterations and/or recommendations------------------------- -----------------------------------•-----------------------------------------•--------------------•---------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------•-----------------------•-------------------------------- <br /> -----•---------------------------•-•-------------------•-----=---------------•-----------• ' <br /> ----------------------------------------------------------------------•----------------------------------------- ------=------------------------------------------------------------------------------------------------------ <br /> w FINAL INSPECTION BY:-----< ' /_--------- ---------------------------- Date------------� t6- L-- ------------------------- <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-4-2M 8-51 Revised W-2100 <br />