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-.,'APPLICATION FOR SANITATION-ii,CAMIT Permit No. <br /> (Complete in Duplicate) 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 <br /> it County Ord- ante No 50 -0 <br /> application is made.in.cor�ipl ip nce.w 7��A-)_ 2-12-- <br /> 4 <br /> JOB ADDRESS ANDATI0P_._1AeZ_7-_ &41a -------------- <br /> ---------- - <br /> Owner's Name- -------- ---------- -- -------- ------- - ------------------------- --------------------------------------- Phone---------------------------------- - <br /> __U ------ --- - -- -- ----------- ­­------------------------------------------------------­­--------------------------------- <br /> Address ----- - ----3------- --- -------- <br /> Contractor's Name-------._----------------❑"_ ----------------- -------------------- ------------------------------------------------------- Phone-------------------- --------- <br /> [-] <br /> Installation will serve: Residence 0 ApYament House 0 Commercial Trailer Court LiL,,Motel. [I Other <br /> Number of living units: _------- Number of bedrooms -------- Number of baths ------- <br /> :�__Vff. - ---------------- <br /> Water Supply: Public system E] Community system El Private Depth to Wafer Table <br /> Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy E] Clay Loam El Clay El Adobe rV Hardpan 0 <br /> '7N <br /> Previous Application Made: Yes 0 N OX New Construction-. Yes No El FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> /.Disfan V-e f orn found f' n-----/0----- M a te r itli- <br /> Sepilic Tank: Distance from nearest well--/ ? <br /> S.-Liquid depth--- <br /> -1V-------- apacity <br /> No. of compartments____21-- . .... ---/ C <br /> Disposal Field: Distance from near well---hPO-tistance from foundation D jie to nearest lot li�e----- --- <br /> Length o ---- f h of trench -2- "1 -------- <br /> -epth of filter r -i-=j I ength----- --------------- <br /> Type of filter mastrlwel�_.___ <br /> l-_ ----- ---�___D <br /> naferil <br /> Number of lines----_ - f each line-40'i9- <br /> Seepage Pit; Distance to near ---------------Distance from foundation(,'� -4-.Disfance to nearest lot line----------------- <br /> [] <br /> ine----------- <br /> El Number of pits----------------------Lining material-----------------------Size: Diamete, _--------------Depth-.------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_________.___.._____________________ <br /> ❑ <br /> aterial------------------------------------- <br /> E1 Size: Diameter------------------------- Depth-------------------------------------------------_Liquid Capacity--------------- gals. <br /> I------------ <br /> Privy: Distance fi�o;'•"n'eWrest well-------------------------------------------------Disiance from nearest building___________-------__--__-_-____._-_____._.❑ <br /> Distanceto nearest lot line-- ------- --------------------------------------------------------------------------------------------------------------------- ----- <br /> if <br /> Remodeling and/or repairing (descr ----------------------�f .. <br /> ----------------------------- <br /> - --- --------- ----- - -- -------- ------------------ ----------------- -----4--e- <br /> --------------------------------------------------------------------------------------- <br /> - - ---------------------- -------- <br /> ---------- --------------------------------------------------------------------------------------------------------- <br /> I hereby certify that 1 �ave prepared this application and f at the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules nd regulations of the San Joaquin Local Health District. <br /> (Signed)_____��Cl--------- ------- ----- ------ ------------------------------------------------------------------------------------(Owner and/or Contractor) <br /> - ­ -_ -_! V - ---------------- --------------- <br /> ------------------------------------------------------------------------------- --------- _--gifle)----- ----------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY-------------------- ------------------ ---------------------------------------- DATE <br /> REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE---: __------------ <br /> BUILDING PERMIT PERMIT ISSUED-------------- _____f� , --------------------------------. DATE------- -------•----I---------------------------------------- <br /> - <br /> Alterations and/or recommendations:_______-:_- <br /> --------­---------------------------------------------------------------------------------- -------- ---- ----------------------------------------------------- <br /> -------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------­----------------------------------------- ----- ------- --- ---- ----- ------ -----------1---- ---------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY------ - ----- ---------------------------- - ----------------- 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 /> E5-9-2m Revisea 1.57 FY.CO. <br />