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- f <br /> APPLICATION FOR SANITATION PERMIT Permit No. ....�P.,7- . <br /> Ili ` (Complete in Duplicate) <br /> Date Issued <br /> Applica�ion is hereby made to the San Joaquin Local Health District for permit to construct and install the work herein described. <br /> This application is made in compliance with aunty Ordinance No. 544. <br /> ` . <br /> LOATION____________JOB ADDRESS-AND <br /> Owner's <br /> Name------ f-------=------- --------------------- - ---------- ---------- Phohe_------------------------ -------- <br /> Address._ <br /> Contractor's Name---------- �---- ------------'------=-------------------------- •---- -- Phone,�,,T�f� <br /> Installation will serve: Residence N Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel '[:] Other ❑ <br /> 6 <br /> Number of living units: I----- Numberof bedrooms . '�--Number of baths-_--__-Lot size ......C�y---------�-_-f��------------------- <br /> I . .,. .. r <br /> Water` Supply: Public system g Community system ❑ Private ❑ Depth to`Water Table .__.- ft. � <br /> Character of soil to a depth of 3 feetSand ❑ 'Gravel ❑ Sandy Loam ❑ Clay Loam) ❑ Clay ❑ Adobe tq_ Hardpan ❑ <br /> Previous Application Made: Yes.[] No Z_ New. Construction: Yeses_ No ❑ k <br /> TYPE OF INSTALLATION AND. SPECIFICATIONS: <br /> (No septic tanVoir cesspool permitted if public sewer is available within 200 feet.) ' <br /> Septic Tank: Distance from-nearest well__,fl/�`t` Distance from foundation_______________7.Mat erial��__.._________._._____ ._._.'Z ✓�__.__.. <br /> No..of compartment's------- _ . Sized_--z'576--- --��6-Liquid dep fh______fP_`�----------;Capacity----------------------- <br /> Disposal <br /> ___-- --Dis osal Field: Distance from nearest well---/1&- 'tgZistance from foundation...... _.,.___.__.Distance to nearest lot f <br /> lin ________________ <br /> Number of lines-------------- ___Len"th. of each line--------.. O------ Wid ��lin <br /> p. <br /> of trench-: --------------- <br /> } : <br /> Type of filter matenal_____1_ _.....SDepth of filter material____.f -----Total length____.____: '________________________ V) <br /> Seepage Pit: Distance to nearestwell_-_____ ' Dsstance from fours{_at�i°ten=__ �.�?__�:.-.1Distancedto nearest lot aine_,��______. <br /> Number of pits_--------f__--------Lining;material_ %_ s: Diameter------S_�-------De'pth____.,_ 2 �--------------- <br /> # : . <br /> Cesspool: Distance from nearest well---- .--.--_'Distance from foundation_.:_:___.._-.......Lining material <br /> --------------------- ------------ <br /> ❑ Size: Diameter _Depth------ --=--- ----- ` Liquid Capacity --gal—s—, <br /> - -- ---------------- <br /> Priv ;. Distance from-nearest well-______------ ------------_________--------- Distance from nearest-building------------_.____________._-_ -__.__.___ <br /> - <br /> • <br /> ❑ _ - _ ------------------ ------ <br /> Distance to nearest;lot:line-"---- ---�-------------------------------- = ` <br /> Remodeling and/or repairing (describe)---------------------------F----=------ -------------_----------------------------a -------------------------- <br /> ----- . ----------------------- <br /> ---•------------------------------- -----=-------------=--=-------------------- :.>--- -----•--------- <br /> ----------------------------- <br /> ---------------------------- <br /> ------------------------------------------------------- <br /> ------------------ ` } g ----------k ------------- - <br /> __ --- <br /> ---_-----`---` ------ <br /> I hereby certify.t have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State la s,' acid tiles and regulations of the San Joaquin .Local Health District. <br /> l .¢�� r2 = ----- -- Owner and/or Contractor <br /> (Signed} ,. •! :.r� ( � / } <br /> e �. <br /> s- ------•------------- ---- Title ----- <br /> By;� - � (Title) �'� -------------------- <br /> (Plot plan, showing siieof.lot, location of system in relation to wells, buildings, etc., can be placed.on reverse side).: <br /> , f - , <br /> I , I FOR DEPARTMENT USE.ONLY ' <br /> i ' • - - - <br /> - APPLICATION ACCEPTED BY--------- --------- ---------------------------------- ----------------------- DATE ---------------------------------------- <br /> REVIEWED BY--- --------------------- ---•------ <br /> ------------------ DATE ---- N <br /> ------- <br /> BUILDINGPERMIT ISSUED--- - ------------ ------------------------------=------------ ---------- .... DATE------------- -------�..-- ---------------------`....--.- <br /> Alterations and/or recommendations:---------------- �' <br /> f ______�_------- _ ------__ _______________________ <br /> _ € ----------___-_--_--;_-.-_--..--.__--- --._ - -.._..__-_....___...____________.___-_---.._.--_----_._..._____________.________.._..__ _._ <br /> 1 <br /> 4 -- - <br /> ----------------------- --- -------------------.-.-_--__-_-.-_-.-_._.__----.--_.-___-._.__---.-_.._-.._...______._.... ____________________._._.__ ___ -------------------- <br /> I <br /> --------------- <br /> . ----------------------------------------=------=------------ -------- - ------- --------------------------------------- <br /> FINAL INSPECTIONBY:.-.--Z.-r-W---p---SS---------------------------- �--------- -- p' <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 /> _a <br />