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APPLICATION FOR SANITATION PERMIT Permit NO­­..---- <br /> (Complete <br /> o. .___..___-(Complete in Duplicate) <br /> (�► Date Issued <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 Or`-nand No. 549 <br /> JOB ADDRESS AND LOCATON_______ 4 __ -_�J __- _ � __�----,___ _ _ <br /> V <br /> ' <br /> Owner's Name---------------- - --- --- ----- ----- A -- ------- -------------- ----= ----------- Phone---------------------------------- <br /> - � s <br /> I Address-------------------------- s <br /> l -------- � ------------------------------------------------f--- -----------....------- <br /> ---- <br /> - -- <br /> ---- --- ---------- --- --- --- <br /> Contractor's Name f - <br /> ----- <br /> f Installation will serve: Residence [ Apartment House ❑ .Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> f Number of living units: _)_____ Number of bedrooms Number of baths :_/___ Lot size -------__.0_0: ___j-_2'__4�_____________ <br /> Water Supply: Public system ❑ Community system [I Private t51"Depth,to.Water.Table%5:ft, <br /> Character of soil to a depth of 3 feet:, Sand E],.,.Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe r�'Hardpan ❑� <br /> Previous Application Made: Yes ❑ No 13--"New Construction: Yes ©---No ❑ <br /> 9 TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) W <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation-------w-_____°_.Material________________________ ________________________ <br /> ❑,XNo. of compartments--------------------------Size.....---------------------------Liquid depth---------- ------ --------Capacity------------ <br /> r <br /> Disposa field: Distance from nearest well-.??...... Distance from foundation--/ ---------Distance to nearest lot line--- ___-___ <br /> Number of lines---'-- ----------- --- --_- '--Length of each line____ ---------------Width of trench------ `r--------------------- <br /> Type of filter mate�ial-_ ,'-,-__Depth of filter material__�__.�f��______Total length_____ �`_£�_-_________________ <br /> Seepage Pit: Distance to nearest well..----__--------------Distance from foundation--------------------Distance to nearest lot line-._--_-_--___-_- <br /> ❑ Number of pits----------------------Lining material------: =---:-Size: Diameter-----------------------Depth----- -_----------------------_. <br /> E <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------------------ Lining material-------- <br /> Size: Diameter = ------- ---'---De th-------------------------------------------------- Li uid Ca acit aIs. <br /> Privy: Distance from nearest well-------____.___--________________________________Distance from:nearest building.._____-.___-_-____-________._______- <br />` ❑ Distance to nearest lot line-------------------=-•-----"'------------------------------------_---------------------- --- ------------------------------------ <br /> Remodeling and/or repairing (descrii�e)_______________ L _" - ��� L- b+-C'�G <br /> -------------------------------_________________________________________________________�__--.__________�____--_____.E. _ _____ _tf__.`__________� ----------------------------------------------------- <br /> G ............. iF----- ---i r� - - -------- ----------------------------- <br /> r <br />!. -------------------- ---------------- ------------------•---r----------------------------------------------------•------•-;------------------ ---------------------- -----------------------'-------------- <br /> I hereby certify that 1 have prepared this application and that the work will �e done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and r9gulations of the San Joaquin Local <br /> Health -District. <br /> C - -� <br /> ----(Owner,-and/or or Contractor(Signed)........ I <br /> _ <br /> N ---------------------------------------------- <br /> BY: C f -�'— --{Title)- � <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on-reverse side). <br /> i <br /> ' FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED 5Y-------------- --------------------------------- ' _Z7-------------------- -•------------ DATE--------�luf% . <br /> REVIEWED BY--------------------------------------------------- __ DATE--------/ <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ <br /> Alterations and/or recommendations:---_____--a_'------------- ---------- ------------ ----------- <br /> ---------- - `s' e ------:: .�5 ::.:::::::::r� � ---------------- <br /> ------ <br /> ----------------------------•--------------------------------------- _ <br /> ----- --------- ---- --------- <br /> :::: -------- �- ----- -- . -------�-- i , .~ <br /> ie s 3. � _ _. ..- -- <br /> ------------------------------------ <br /> ---.___._ r____ _- � ------------------------- <br /> FINALINSPECTION BY:..-------------------------------------------------------------- Date-------------------------------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfree+ 814 North "C" S+roe+ ! i <br /> Stockton, California Lodi, California Men+eca, California Tracy, California �. <br /> ES-9-•--2M 10-52 Revised W-2100 <br />