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4 -----APPLICATION FOR SANITATION PERMIT Permit No. <br /> in Duplicate) . tea <br /> (Completep � bate Issued �_r�___ � <br /> pplication 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 Grdinanc_e No. 549. <br /> OB.ADDRESS AND LOCATION --------------�. C K <br /> P <br /> .. . hone <br /> ------------- <br /> Owner's-Name--------------- <br /> S/[f� � _ it <br /> Address__ . ��----- ----- --------�-'-�--- ---------------------•-----------------------•-----•----------------•• -•---------------- <br /> 1 �.- " -me � '"� -- Phone----••-•--------------------------- <br /> Contractor s"Name ---------------•------------------- = <br /> Installatioln wiil'serve: Residence ,❑ Apartment Douse ❑� Commercial Trailer Court ❑ Motel Other ❑ <br /> ' Number of living units: _______- Number of bedrooms ---------Number-of baths -_�__ Lot size _____ 8-.-�i-o---------------------------------- <br /> Water Supply: Public system El Community sy tem 0 Private E&-,-Depfh to Water Table ------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ 1Gravel El Sandy'/Loam El . Clay Loam ❑'`Clay ❑. Adobe'�Hardpan E]Previous=Application Made:-- Yes E]—No`a;i,New Construction: Yes r o ❑ <br /> TYPE'OF INSTALLATION -AND SPECIFICATIONS,- <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> 3 <br /> Septic Tank: Distance from nearest well__I. __O-_.___Distance from foundation___ _ <br /> Material- -------------- <br /> 43 <br /> - - --------------- <br /> ®� No. of compartments______�2 --�____.__Size__!_x_ X_, -_Liquid depth_______`F'�__..�_-- Capacjty_____ O `(� <br /> 1 <br /> . Disposal F' Id: Distance from nearest well__,._:_--_-_,Distance from foundation-_-_1 v_______.Distance to nearest lot line-_--__S____. �l <br /> Number of lives__________ 's.- Len th�of.each line_ ____ S�.Width of trench----------- ---- <br /> �� - r <br /> --------------- <br /> Type of filter material__ __Depth,of�fiifem terlal____.__.1.�- _-____Total length-'------------_ _ 7_..-__________ <br /> Seepage Pit: Distance to nearest well------------ sistance-�,rom foundation___________________.Distance to nearest lot line- __-_.___.______ <br /> 0 Number of pits----------------------Lining iT---------------Size: Diameter-----------------------Depth--------------------------------- <br /> 3 Cesspool: Distance from nearest well------------------Dstanee from foundation__________________ ning material-_.___ ______________ <br /> ❑- Size-: Diameter- " -------- ---- <br /> - <br /> --------- ------- --7Liquid-Capacity----------------------------- <br /> Priv �' Distance fro nearest well ___________ __ A_:_.::=Distance from nearest buildings ::_______._-_--__..._--___.____ _ <br /> ❑ Distance to nearest lot line--------- ----------------------- ° ------------------------------------------------------------ - L_------------------------------------- <br /> "--------------------------------.---- <br /> Remdeling and/or repairing (describe)------------------------------------- --- ------------------------------------------------------------------------------------------------------- <br /> '% ___­-I----------------------------------S _________________ <br /> ---•---------'---•-----------------------------.......-------------------•----------- <br /> e --------------------------------------------------------------------------------n <br /> hhereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County <br /> ordinances, Stat aws and rules and regulations of the San Joaquin Local Health District. <br /> (signd -" '}`-'-'-�------------- --------------------------------------------------- ------------- ----- tO,wner and/or Contractors <br /> 1 ---- -- <br /> BY: -------------- -- (Title) ------------I <br /> --------- -- - <br /> (Plot plan; showing size Of-lot, location of system in relation to wells, buildings, etc., cart�ge-placed-on reverse side). <br /> { FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- -- -•------------1 DATE-------- ?,? <br /> f C <br /> -- -••------------ <br /> REVIEINED BY-----------------------=------------------- --- ------ ` .._.. <br /> -------'` DATE------------------11.---------------------------------------- <br /> DA •----------BUILDING PERMIT ISSUED_________________ <br /> Alterations and/or recommendations------------------------------------ <br /> -r -------- -•-- - ---- --- <br /> ------------------ <br /> ------------- <br /> -------------------- <br /> ------------ <br /> OtK4 <br /> lJ tet? l/ ----------- •----- ------------------- <br /> ------------=------------------ - <br /> - -- r <br /> 1 L <br /> FINAL INSPECTION—BY: "'=.. ---- `� R _. ..,M .w �..,�. �...�.Date.._..�- ---------- - --- <br /> --• L) , <br /> SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> 130 Soufh.American•Street •'-t-'"`•"3WVe t Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, CaliforniaLodi, California Manteca, California Tracy, California <br /> ES--9-2M I0-52 Revised W-2100 <br />