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VrpaL 4 q -1 KA, kqj- r 'N aw,,u <br /> t�v Permit No. .___$. <br /> PLICATION FOR SANITATION PERMIT - -- � <br /> (Complete in Duplicate) Date Issued .--.y <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 compli ith County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION-- -- �. -6 (, -�•----- --------------------------------------------------------------------- i <br /> Owner's IN e �' •------.. ------ ----------- -------- -------------- -------- ------------------------------- ------.... Phone__�'� `" <br /> U <br /> Address-----` ` �' ° • -•---------------------------•----------.--------- <br /> Contractor's Name-- -��_._ .-_A -- . ------- F ----.--- Phone_ ...3 ------ <br /> �. <br /> Installation will serve: Residence 6KApartment.House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___I____ Number of bedrooms __ __ Number of baths ____I__ Lot size --------- _________________________ <br /> Water Supply: Public system ❑ " Community system ❑ private Depth to Water Table <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeff"'Hardpan ❑ <br /> Previous Application Made: Yes ❑ No [<New Construction: Yes-&No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic,lank: Distance from nearesr well--.-.-------------Distance from foundation---------------------Materia9_________--_._--___--____.____________________- <br /> No. of compartments---------- ---- ----------Size------------------------••------Liquid depth------------------------..Capacity----------------------- <br /> Disposal Fi Id- Distance from nearest well.................Distance from foundation--------.-----------Distance to nearest lot line----------------- <br /> Number of lines------------------------- ------Length of each line-------------------------,.......Width of french----------------------------------- <br /> Type of filter material...... .............._-Depth of filter material_-----7_-.____... .-.--Total length_____________._____------..-___________._ <br /> Seepage it: Distance to nearest welL_�Sf:________Distan from foundation_:t3Al�;?k_v _Di f nce to nearest lot lireJ�_...--.. N <br /> Number of pits----V.__-,---___._..Lining material-- ize: Diam ter_____ . .__ --------Deptn___._2"y____________________ �J <br /> Cesspool: Distance from nearest well-___-__.____.._-Distance from loundation------------------- Lining material----------------------------.__-__.___. (`f� <br /> ❑ Size: Diameter------------------------- - ----------Depth------ --------------------------- ------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well.---------_..----------------------.............Distance from nearest building____.________.-_--.-_-_......._______- <br /> ❑ Distance to nearest lot line--------------- -------------•---- ------------- •--------------•--------------------- --------------•--------------------------------- <br /> Remodeling and/or repairing (describe):------------------------ -- ----- "... ----------. r" <br /> --- :::: : ::: ---------------- -- <br /> j -------------------------•------------•------ -------- ----------------------------------------------------------------------------------------------------------.------------------------------- <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 /> I .�. ` <br /> {Signed)-- ------------------------------------------------------------------------------- ...... <br /> -- [Owner and/or Contractor) <br /> rBy=----------- -- - ----- -- ----------------------------- -----------------------------------------(Title) r - ---'------------------- ---------------- <br /> [Plot plan, showing si of lot, loci afi oN of system in relation to wells, buildings, etc., cart be placed on verse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------------------- - --- ---- -� DATE - --------------- <br /> g----- <br /> REVIEWED BY-------------------------------------------- ----- -•-_ . ,,� _------ .--- ------------1----- DATE = <br /> ! --- --•------------- <br /> BUILDING PERMIT ISSUED------------•--------------- DATE <br /> ---------------------- <br /> Alterationsand/or recommendations--------------------------------------------- ----------_--------------•---------------------------•------------------------•-- ------------------------------- <br /> ------------------------------- ----------- ------- -------------------------- - ----------------------------------- -----------------------------------------------------------------------------------------------•------- <br /> ------------------------------------------------------------------------------------ -------------•-- ---------------------------•----------------------------------•-------------------------------------------------------- <br /> ---------------------------------------- ------------. --------------- -- --- ------------------------ --------------------------- -•- ----------------------•-------- I I <br /> FINAL INSPECTION BY:_,_�e._-- r: ------------ ----- Date__ Q `-------------- ------------------ - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> , <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-5-2M 145446 arw000 12-s4 <br />