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APPLICATION FOR SANITATION PERMIT <br /> Permit No'. ....__ �� <br /> = <br /> e <br /> (Complete in Duplicate) <br /> a$L <br /> E . J ` /.5 -" ! <br /> pate Issue Q'-----------------------/ <br /> Applica*ion 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 OrdinanGp No. 549. <br /> JOB ADDRESS AND OCATION A..--- _--�--- ----- -. - ---------- --- ------ ..-------- --••-----'�" //�� ------- <br /> /� Phone U_. L---gzk—T <br /> Owner's Name---r�`-' --- - ----- -•-•---- --- A ° k -- ........ <br /> Address----------- t-------- ------------------------------------••----------------------.........------------------------------------------------------------------ <br /> Contractor's Name----,------- -- -------------------------------------------------------�------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence M/Apartment House ❑ Commercial ❑ Trailer Court 1_ Motel [:1Other E]Number of living units: - /_ Number of bedrooms _Z-. Number of baths ___L___ Lot size ______________________--__________._____________________ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. F <br /> Character of soil to a depth of 3 feet: Sand❑ Gravel ❑ Sandy Loam ❑ Clay Loam [I Clay [I Adobe Hardpan [jPrevious Application Made: Yes El No W New Construction: Yes [g] No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: \� <br /> (No septic tank or cesspool permitted ift444 <br /> blicser is available within 200 feet.) <br /> Septic Tank: Distance from nearest well Dista e fr m fo dationjp___________ -Callo. of compartments--------- ------ ize_��-- - ------Liquid �epth -- --- ------ parity---_-- - - ----- <br /> Disposal <br /> ---- . <br /> i osal Field: Distance from nearest well _ _.__ Distance from foundation/P__T�"�'--Distance to nearest lot li e�_, -------- <br /> Iwo <br /> _.L <br /> D sp r r <br /> . <br /> Number of lines__________ _____ _ � _ ,Length of each line_______________ Width of trench_____�C__ .__,_�__--__________ . M' <br /> f Type of filter materil t1�Depth of filter materia l------ length------------/.��_________________ <br /> Seepage Pit: Distance to nearest well--------------.------Distance from foundation-------------------.Distance to nearest lot line________________ <br /> El � Number of pits------- --------------Lining material--------------.--------Size: Diameter-----------------------Depth----------------------..-----.--- <br /> Cesspool: Distance from nearest well--------- _____Distance from foundation-----------_--------Lining material----_-----____.____________________ <br /> ❑ Size: Diameter------------------- --------- ------Depth-------------------- --------------- -------------Liquid Capacity----------------------------gals. <br /> --___.i___________________Distance from nearest building Privy: Distance from.nearest well.--------#_-- --- �' g------------------------------------------ <br /> Distance <br /> - ----------------------------------Distance to nearest lot line---------)------=---------------------------r`--------------------------------- -------------�- -------"-------------------------------- <br /> l � r � 1 � <br /> ..�.."' .------------------- -------------------- -------- -------------------------------------------------------- <br /> Remodeling and/or repairing [describe)__________________________ __ _ <br /> I f i <br /> i i . <br /> I i I. 1. ' -- --------- <br /> --------------------------------• ------- -----------...------------------------------------------------- •------------•--••-------------------------------------------------: ----------- _------- - <br /> I hereby certify that have prepared +his application and that +he work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rule nal re ulations ofAe S Joaquin Local Health District. �- <br /> (Signed)----- - - -- ------- I-- ---------- ---------- ---- -----------------------------E------------------------------------:-------------(Owner and/or Contractor) <br /> By:------------­­: ---- -- - ---•--------------- ---------------i---------------------------,------------------------------(Title)---------------------------------------------------------- ---- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side)., <br /> ! N w + f <br /> FOR DEPARTMENT USE-ONLY <br /> 4 APPLICATION ACCEPTED BY DATE�'--- - ---------------------------------- <br /> ----------------------- --------- ---------------------- <br /> REVIEWED Ii- - ----I----------------------------------------------- ------------- D <br /> DATE-- --- -------------------- <br /> BUILDING PERMIT ISSUED-------- --------------------------------------------------------------- <br /> --------------------------------------•---------------------- DATE <br /> Alterationsand/or recommendations:--------- ---------- - ------------- ---------•----------•-•--------- ----.. ------------------------•--•----------------------------------------------- <br /> -•------------•------------•-----------•-----------•-------------•-------------------------------- -----------------------------------------------------------------------------------------------------•••---•-------------- <br /> FINAL INSPECTION BY:, -- --- ----- Date------/< ------------ ------77:%�- <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 ; Revised W-2100 Jr �► <br />