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APPLICATION FOR SANITATION PERMIT Permit No. C3 _zJ <br /> � (Complete in Duplicate) <br /> Date Issued <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 compliance.with County Ordinan No. 549. <br /> JOB ADDRESS AND LOCATION - — -� @-------------- - .__------------------------------------------ <br /> Owner's Name = -L CIti-� =----F---- --- ------ Phone------------------------------------ <br /> . .-.. _ = <br /> arc5------ , -.. -. <br /> --------------------------------------- <br /> Address-------------- - <br /> Contractor's Name------------------------------------------------ fi -------- sem------------------------- ------ Phone-_7 <br /> Installation will serve: Residence 2(l Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _ -_-_ Number of bedrooms _Number of baths J____ Lot size _____ ----__}__.____-__ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table�_eft. <br /> Character of soil to a cIepfh of 3 feet: Sand ❑ Gravel ❑ Sandy-Loam ❑ Clay Loam [] Clay ❑ AdobeA Hardpan ❑ <br /> Previous Application Made: Yes ❑ NoNew Construction: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ! I 1 <br /> (No septic tank or cesspool'permi+ted if public sewer is available within 200 feet.) } <br /> S _ ' Tank: Distance from nearest well-----------------Distance from foundation________..____-.__.Material _____________.________-_-_-______.___________- <br /> No. of compartments---------------------- - Size--- —----------------------Liquid depth---------- ------ ------q Capacity-__--------------- --- <br /> � <br /> osal Feld_ Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> Number of iines-----------------------------------Length of each line------------------------------Width oftrench---------------------'�`---------- <br /> Type of filter material---------_ __ .___._Depth of filter material___________________ Total length-__.______________________________________ <br /> Seepa a Pit: Distance'to nearest '­--------- Distance��++f�rrc6 fo ndation_.-------------------Distance to nearest lot line_- <br /> Number <br /> of its___ Lining materially __ � <br /> .Size: Diameter_c5- -""_______Depth__ '__-_ <br /> Cesspool: Distance frcm:nearest well-________--_____Distance from foundation--------------'____Lining material_--_____________________.____________. , <br /> ❑ Size: Diameter--------------------------------------Depth--------- ------------------ -----------------------Liquid Capacity----------------------------gals, Q <br /> Privy: Distance from nearest well_________________________ ____________________ti--Distance from nearest building--------------------------------------___ <br /> ❑ Distance'to-nearest lot-line----------------=--=----------------------=------------------- ------------•------------------------------------------------------ <br /> Remodeling and/or repairing (describe):--------------------- ------ -----------------------------------------------------------------•---------------••-- •----------..-....._--------- <br /> a <br /> ------------------------------------ ,------------------------••--------------------• •--------------- -I----•-•------•-------•------------------------•------- <br /> --------- <br /> ! herepState <br /> fy #ha+ I have prepared this application and that the work will be <br /> in accordance with San Joaquin County <br /> ordinancesaws, and ru! s and regulations of +he n Joaquin L cal Health District. <br /> Si ned ' # r Contractor( 9 }----- - -------- --- ! i <br /> -- - I <br /> By:..-----••-------------- ---------------•------------------------------------ ^•�-- - ---------------(TitlelFe <br /> r ----------------- <br /> (Plot plan, showing size of lot, location of system in rel ion fo wells, buildi s, efc., can be plan reverse side}. <br /> F R DEPARTMENT US9 ONLY <br /> APPLICATION ACCEPTED BY----- ---- ----------------------- - < R -- ------ DATE A/1> <br /> REVIEWED BY-* <br /> -- --------------- -------------------f�--------------------- DATE--------f-------------------------------------------------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------•------------------------ DATE---------------•------------------------------- - - --- <br /> Alterationsand/or recommendations--------------- ------------------------------- --• --•-•--•--------------------------------------------------------------------••-------- ---- --=----------- <br /> I ---------------------------------•-------•---- --------------------------------------------•-------------•------------------------------------- ---_-..._.------------------------------------•-•----------•---------•- <br /> e I - <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------_--------------------------------------------------------------____. <br /> ______________________________________________ ___________ - � <br /> •.__--_-_-___.'____ ._____ :______.____-_.-.-_____._..._____________.___..__________..________._________._.___- _.-___- -------_.-______---_________________._ <br /> r -J7 <br /> FINAL INSPECTION BY:---------------------= W_ Date--------- - ---------------- ------------------------------------- <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 /> ES-9-2M Revised W-2100 <br />