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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) --Date Issued -------/3..5 <br /> Appli6a4ion 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 Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION...... --- -------------------------------------q <br /> -- --------------------------------------------------- <br /> Owner's Name----- -------------------------------------------- -----------------------------:---------- Phone-__-----_------- ----------- <br /> Addre'ss - ----------------------- ---------------------­-------- -----------­---- ­---- - --.-..-.-.-.-.... <br /> Contractor's Name------ ---- _ ­ - - -- <br /> - - <br /> Installation will serve: Residence [Apartment House I-] Commercial E] Trailer Court ❑ Motel El Other [__1 <br /> I <br /> Number of living units: --/-- Number of bedrooms -------- Number of baths -,/-- Lolt size------ --------------------------- <br /> Wafer Supply: Public system El Community system"El Private Ug-'Depth to Wa'terg Table 3s_ ft. <br /> Character of sail to a depth of 3 feet: Sand E] Gravel E] Sandy Loam F1 Clay Loam El Clay 0 Adobe a--garcipan 0 <br /> Previous Application Made: Yes E] No 2 New Construction: Yes [�No E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is'a'vailable within 200 feet.)( <br /> , I i .1 . ... .. e <br /> Septicr Tank: Distance from nearest� well_47P--------Distance from foundation'---1-4).............._._.Material-__-_ 0------------- .... -------- <br /> /' t— - -------- <br /> No:� of compartments ;?--------------Si,eL--5-K_,X_!yd-----__-_Liquid depth___- a 'Capacity---- S4-:----- <br /> Disposal Field: Distance from nearest well---;74........Distance trom toundafion�-__/e��' ------ <br /> ------ Distance to nearest lot line___/15�_-, T11 <br /> Number of lines-------- -----------------------Length of each line-----2_�,O---------4f <br /> -------Width of trollc ------ ---------------------- <br /> Type of filter ----Depth of filter _---_.-Total length----i j�j4�-------- ---------- <br /> p I <br /> Distance to nearest well----------------------Disfanc _-P- Distance to nea5resof Sline_______._________'Seepage Pit: e from foundation.,__ <br /> El Number of pits.---------------------Lining material--------------------------Size: Diameter------------------------D6pf h--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation_...._.__.:._._lining material---------------------------- -------- <br /> -4 zae C city <br /> Size: Diameter,--- ------------;------------------ --------- I <br /> EL `L qui Ca ----------------------------gals. <br /> Privy: Distance from nearest well-----------------------------------------------.-Distance from nearest building--,---------------------------------------� <br /> Distance to nearest lot line__________________________ -------------------------------------------------------------------------------------- --- <br /> Remodelingand/or repairing (describe]:------------------------------------------------------------------------------------------- --------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------:------------------------- <br /> -------------------------------------------------------------I--------------------------. ---• ------------­­­-­-------------------- -------------------------­----------------------------------- <br /> -----------I------------------------- - -------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 0, <br /> ordinances, State laws, and rules and regulations f theSan Joaquin Local Health District. <br /> (Signed)---- ---------- ---------------------------------------------------i 'Dwner Ind/or Contractor) <br /> IPL-- ___------------------------ --- -- <br /> -----------' <br /> verse <br /> (By:-------------- --------------------------------------(Title <br /> (Plot plan, showing siie of lot, location of system in r� tion to wells, buildings, etc., CanLbe place on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> ---------------------- DITE-:-::-. <br /> .......... <br /> APPLICATION ACCEPTED BY________________________________- - ATE -.-:---- <br /> REVIEWED BY------------------------------------- ------ ---- ------------------ D - - - - - ---- --- <br /> V--- ----------------------------- --- -------------------------- <br /> BUILDINGPERMIT ISSUED----------------------------------- --------------------------------------------------------------- DATE.--------------------------------------------------- ------ <br /> Alterationsand/or recommendations:---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------i-------------------------------------------------------------------------------------------------------- ---------------------------­..........:----------- -----------------I--------- <br /> --------------------------------------------------------------------------------------- -------- -------- ------- ----------------------------------------------------------------------------------------------- ---------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------- <br /> ---------------------------------------------------------- ----------------- ---- --- ----------- ---------------------------------------------------------------I-------------------------------------------------------------- <br /> FINAL INSPECTION BY:- <br /> -------------------------------------------------------- Date---------.-- ------------------ <br /> --------3_4 <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 /> E5=9-2M Revised W-2100 <br />