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APPLICATION FOR SANITATION PERMIT Permit NoA .._--- <br /> 4,6"'o- � F f,-"�?& I <br /> W <br /> �. <br /> (Complete in Duplicate) <br /> . .� Date issued�_+__'y``S� <br /> Application is hereby made to the San Joaquin Locaf"Health District fora hermit to 6nstrFctand install the work herein de ib <br /> This application is made in compliance wit County Ordi nce No. 549. perm <br /> a ct int rl� ` /r km r ��nQ�r <br /> ' S'1Q f- <br /> ----- <br /> JOB ADDRESS AND A ]ON------- - . <br /> ----i�- --- •----- <br /> Owner's Name--------- ------ ----------------- - ----------------------------------- -- --- -----------------------------------... Phone---------- <br />-A dress------------- ------ -- ------------ <br /> Contractor's Name------i--------------- -----. Phone----------------------------------- <br /> Installation will serve: )Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑. erLZ <br /> ❑ <br /> Number of living units: _ -r;-- Number of bedrooms .--- Number of baths -/-- Lot size ----- -_--:---f <br /> Wafer Supply: Public.system '❑ Community system ❑ .Private K'Depth to Water Table-:?�Q ft- <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ . Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe E) Hardpan <br /> Previous Application Made: Yes E] No IX New Construct ion:}Yes ,-No E] <br /> TYPE OF INSTALLATION AND-SPECIFICATIONS: ' <br /> (No septic tank.or cesspool permitted if public sewer is available within 200 feet.) r <br /> Septic Tank: Distance from nearest well----!7 --Distanc fro n�pundati Materi ------------------------- <br /> Size <br /> ' <br /> A- , - <br /> No. of compartments ' nn Size •------------------ squid depth-- CapacitY <br /> Disposal Field: Distance from nearest ell....(Pa_-Distance from foundation-__-2 �_-Distance to nearest lot line-___----`✓----- <br /> 0 <br /> --- <br /> Number of lines---•------ --- --------- -�}_Length of each line---------_-�-a-----.Total <br /> of trench------�..�-------------------- <br /> /f <br /> Type of filter materia-:I-5�2f- _Depth.of filter material__-_----f_ -.Total �24 n <br /> Seepage Pit: Distance to nearest swell--- -/_(� Y-'Distance from foundation----____ -----.Distance to nearest lot line__.__..`. <br /> `��--rl-y;---�C l�t[� �P'• ((gyp <br /> Cess ool:. D stance f omsnearest well -Linin Distance tom fo ndation�•ameter----_--- .F-►-_-----.Depth_:-. -----j <br /> 1 p _ _- g materiel � / <br /> p J Lining.aerial- -- -------------- -- <br /> ❑� ..- -_�,�Size: Diameter.-_, --Depth -- —:, y.Liquid4Capacity .. : ,. ..gals. <br /> R r ---:_Distance from nearest'buildrri <br /> - Privy: Distance from nearest well--------- ------ ---- --- --- ------ 9------------------------------------------ <br /> 4. <br /> ❑ 6 <br /> Distance to nearest lot line------ --------- ---------�-------- -----------------------�--------•-------•------------ ------f-------------------------------------- <br /> Remodeling <br /> ---------------- - --------- <br /> Remodeling and/or repairing (describe):_ ------------- ---------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------- <br /> ----------------------------------------- <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 egulations of the San Joaquin Local Health District.'.'N <br /> {Signed}----------- ------------- -- --R-'..r----------- ----------- ------ -------------------.--.-- = --------------- (Owner and/or Contractor) <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 ----------- --------- DATE ^ <br /> REVIEWEDBY--------------------------------------------- --------- -------------------------------------------f----------­-------------- DATE----------------------------- -•---•----------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------------------------------------------------------- •- <br /> Alterations and/or recommendations*-------- -----------=-----------•--------•------------••---•----------------------_---------------•-------------------- .-•-------------- <br /> t <br /> ------------•---•------------------------•------•------------ <br /> i <br /> -------•--•----------------------------- ----------------------------------------------•------------------------------------------------••--------------------------------------------------- <br /> --------------------•----------------------------- -------•----- ---------------------------------- <br /> - - - Date •-• ------ `...— <br /> FINAL INSPECTION ---" .-- - <br /> SAN JOAQUIN LOCAL HEALTH DIS ' <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 /> Z-9---21A Revised W-2100 _�' <br />