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APPLICATION FOR SANITATION PERMIT Permit No. .... v.�........... <br /> (Complete in Duplicate) Date Issued 5�" <br /> Applicaa-ion is hereby made o the''Sa Joaquin Local Health District for a permit to construct a and install„the-work-herein described. <br /> This application is made incompliance with aunty Ordinance No. 549. ? rJ <br /> _ <br /> JOB ADDRESS AND rLOCATION _-- --- --} _. -_._--]*,ep - <br /> Owners Name.............. -P- ------� - - -- - - - ------------ - ----------------- <br /> --- -------- Phone0)&RALd-S <br /> -07Z <br /> Address---------------•----------------- ` _�_.�_.�-- ------ --- --- L --------------------------•--•----------------------- <br /> 77 777+7� <br /> Phoe11 "��ZtContractor's Name------------------- -- - ------- Y7 <br /> Installation <br /> will serve: Residence Apartment House ❑ Cimmercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: =__L Number of bedrooms -_ Number of baths _1-__ Lot size '________________________________ <br /> Water Supply: Public system❑'Community system ❑ =Private Depth to Water Table _�ft. <br /> Character of soil to a depth of 3 feet: #Sand ❑ Gravel ❑. Sandy.Loam ❑ Clay Loam ❑ ClayK Adobe Ef Hardpan ❑ <br /> Previous Application Made: Yes ❑ Noia New Construction: Yes ❑ NoR( 1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: Tq`I <br /> (No septic tank'or cesspool"permitted if public sewer is available within 200 feet.) } � <br /> Septic Tank- Distance from nearest well-----__----------Distance from foundation__________-----------Material ________________________________.___________- <br /> ❑ � No. of comportmems----------------`----------size--------------------------------Liquid depth-------- <br /> `------------------Capacity_------------------- <br /> Disposal <br /> ....------ ------ <br /> p " d: r t A _._._Distance to nearest lot line_________________ <br /> Dis❑osaField: Distance from ;nearest well...... from foundation Width of trench__________ ______________________ <br /> lSn Number 01:-lines__ ________ Length of each line________________________ <br /> ` Type or filter material------ -----------------Depth of filter material-___---------___-;F__-Total length--'-------------__------------------------ <br /> Seepage Pit: Distance to nearest well_ A0_ 77---Distance�jrom,fodhdation_____.__._.____....Dis yce to nearest lot iine__ __A____ <br /> [� Number of pits_ -Lining material__P LC_ __._�,,y__Size: Diameter.s..j______________.Depth_�__..( ----- <br /> -. <br /> Cesspool: Distance from nearest well----- -----------Distance from foundation____---_.f-_______.Lining material-__________________-/ <br /> _ Size: Diameter-------- ---------- -=- - �.�Depth�---.--------v-. -=x ~:¢ Liquid Capacity-..:---_----- -i/ -:--gals. V . <br /> ❑ _ r <br /> Privy:: Distance from nearest well ----- ---------------------------_---.- ---Distance from nearest building_-:._.--.-__----------_--_ <br /> --------------------- ------------------------------------_:______-___. <br /> ❑ Distance'to nearest lot line_____4-.--`-------------------------------------------------------------- s _ <br /> ------- <br /> Remodeling and/or repairing (describe):__- ____;__ ` <br /> ----- ---------- ---- -----------------•-------------------- <br /> = -- ------- <br /> 1 r i "1 <br /> -•-•----------------------------------- <br /> --------------------------------------- -------------------.------_----•-------------------•----------------------....... F <br /> -----'--------------------------------------4--------••-----------------•---•-------r-.--.---•---------------------------•---'---------------•-••------------------------------•--------------------------------------------- <br /> I hereby certify that rr!,ves:a�)n <br /> ared this,app'cation and that the work will done in accordance with San Joaquin County <br /> ordinances, State laws, a regulations the San Joaquin Local Healfh L District. <br /> s r ' !�'""-- `-..- wrier and/or Contractor) <br /> (Signed) -. --- -- -- <br /> BY�--------- ------- C (Title) r -------------------- <br /> (Plot plan, showing siie of lot, location of system in relation to wells, buildings, etc., can be.place n reverse side). �- <br /> � , k <br /> 3 FOR DEPARTMENT USE ONLY'' <br /> APPLICATION ACCEPTED BY----i -----------------------------l --i------------'------------------------­-:'..-------- DATE-------------- "" � ��----- <br /> REVIEWED BY------------- -- --------------------------- <br /> _---. - - -�•-� -- -- <br /> --- -------------- ------ -- ------------------------------------------- DATE----- ------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED------------ -------------------------------------------------------- ----------------------- DATE-----------------=`------- --------------------------------- <br /> Alterafions and/or recommendations:----'------------- - -•--------------------==------------.. ------------------- - --=----.:.-------•---.......r..-----•---...-•-- <br /> -------------------------------------------------------- -------------------•------------------------•-•----------=------------------------- ---------------------------------------------------............---- <br /> ---•-•------- --- --------------•---------------•--------------------------•----•--•-------------------------------•--•----------------------------------------------------•--------------- -------------------------- <br /> ----------•--•-•------------------ - <br /> i <br /> FINAL INSPECTION �_ � - '------ Date_ ._. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-4-2M ; ,,`Revised W-2100 _ <br />