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y APPLICATION FOR SANITATION PERMIT Permit No.-c5- 1:4 <br /> (Complete in Duplicate) <br /> Date Issued/ - . <br /> Applica+ion is hereby made to the San `Joaquin Local Health District fora permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance o. 549. ) <br /> JOB ADDRESS AND .LOC ION-- -- <br /> Owner's Name---------------------- ---• . . ..... G� ;° Phone _. . /�.1 z <br /> .r.. <br /> Address !,--- ---• -- ----- ---------A -- ----------------------------- --•--- <br /> Contractor's Name----- ------ - -- --------- ---- ---------------•---------------•----- •------------------•--- P h o n e//_ ---�? <br /> • r-�_4 1 <br /> Installation will serve: Residence �partment'House'❑-"Commercial ❑ Trailer:Court F]. <br /> -Motel Other ❑ , <br /> Number of living units: ._-'Number of bedrooms _.:Number of baths . - �Lof'size -------------_---_, ---------------------- <br /> Wafer-Su pply: <br /> _----_--__-Water-Supply: Public system 0%mmunif--system"ElPrivate ❑ Depth to Wates• Table <br /> Character of soil to a depth of 3 feet' Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ :Clay ❑ Adobe 2--fi-ardpan ❑ <br /> Previous Application Made: Yes . No <br /> New <br /> ; Construction:- Yes•B-11_011 � <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> t <br /> (No septic tank or cesspool permi#ed'if public sewer is available within 200 feet.) <br /> eRtic Tank: Distance from nearest well----------------- from foundation_-__................Mate'vial-----_-.-___-------_______--_----____-_-..-_.-- <br /> No. of compartments----- ..... - --------Size------••------- --------- -----Liquid.depth----- --------------Capacity----------------------- .►: <br /> s ,/d "i . , <br /> isposal F' d: Distance from nearest welLh��:Distance from foundation___ __ ___Distance to nearest lob,line___�._____ <br /> Number of Eines-_ -- ---._;__-_ -_ _. 'Length of each Ii ---__---�_- __�� -_Width of trench_"_.___'�_.�� <br /> 4 4 k -- r <br /> "h E Depth"of fil#er`mater�aL__.L __.______.:Total length_..---___ .� : <br /> Type ar filter m tenial_s'__.. -_ <br /> p g i M1� l ' <br /> See a e �t: �iUtabnece oto nts rest well:_- -Distance om foundation---_7__�_______iDistance to nearest lot lin_e_..`�__..`_._•- � <br /> p ---_--_-----Lining material_4.—fi? Size: Diameter.-- ��-------Depth---.-oZ`5 � <br /> Cesspool: Distance from nearest well_________________Distance from foundation_=..-.-.____-_ __.Lining material_____.--- ____-_____._.__________; <br /> ❑ Size: Diameter- - ---`---------------------------- Depth-------------------------------"------------`-----Liquid Capacity------------------ gals. f <br /> Privy:i. Distance from nearest well---------------------------------------------------------Distance from nearest building--------------.-----_-____-_____2____._._. <br /> ❑ Distance to nearest lot line._.__ ...__ ' <br /> -----------------------------------------------•-------------- - <br /> Remodelingand/or repairing {describe):--------'------------------------------------••----------------­------------------- ------------------------------------------------------------------------------------------------------------------------ <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) F - __-._ {Own and/or Contractor) <br /> a -- <br /> Plot Ian, showing size of lotocac on orela 'to wells build {Title)___ _ ___ _________ __ ____ _____ <br /> - ------------ <br /> { p g I y buildings, etc., can be placed on reverse side).' <br /> E FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--:- --- ---------------------------- ----------------- DATE = r� + <br /> 1 <br /> ---------- c5 <br /> REVIEWEDBY---------------------- -----�---------------------------------------------�-�----=---:---------- ----- DATE------'!'=--"..�'= <br /> BUILDING PERMIT ISSUED = - =---- ------ DATE---------------------- <br /> Alterations and/or.recommendations=--------------------------------------------------------------------------- -__.... <br /> ----------------------------------------------------------------------- <br /> -=-'--------------.-------------------.»_ - f <br /> ---•-----------------•------.-----•-------------I——------------------...._ <br /> ---- ----------- -------- - € - <br /> 1 <br /> " -__-----------•--------------- .------------•--------' <br /> I. <br /> Date <br /> FINALINSPECTION^BY-- --- -------- -- --- A - <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 /> 1 ES-9-2M ; Revised W-2100 <br />