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' APPLICATION FOR SANITATION PERMIT Permit No. .�-�f.....�...=Z- <br /> (Complete in Duplicate) (p <br /> -r Date Issued-/___.. <br /> V <br /> Approzeionl" 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 Ordinanc( -No. 549.. ; <br /> JOB ADDRESS AND LOCATION_... ------------------- — - <br /> Owner's Name_... i .- __... .�. ---------------------------Phone--- til.-...._ ------------ <br /> -----• -------- <br /> Address------------------ ......--------------------•Z- —e ------- -------------------•------------ ---------------------•---------------------- ----------------------------------- . <br /> Contractor's Name------------------•------•--------�ed....... ------------- I-A"o------------------------------------------- •-------- Phone---•-----= ------ <br /> s <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---I— Number of bedrooms --2---.�- Number of bath_-I___ Lot size -�___�_—x <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 E] Clay ❑ Adobe 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.)SpF4 <br /> tic Tnk: + Distance from nearest well-____.`---------Distance from foundation--------------------Material------------------------------------------------ <br /> �" <br /> No. of compartments------ -------------- ---Size---------------------------•---Liquid depth---------------- --------Capacity----------------------� <br /> Disposal Field: Distance from nearest well®�._._Distance from foundation__ <br /> Z0.0 <br /> Disposal to nearest lot ling* �__ _ <br /> s <br /> Number olines_______ _________ Length of each line______ . _........___.Width of +ranch.__ _ -------------------- <br /> I <br /> ,t - <br /> Type of filter material_:J_��__ ----Depth of filter^material-_..�_ _�°_-____..Total length__-_..7-+.T`-'_____________________ <br /> Seepage Pit: Distance to nearest well___--------------------Distance from foundation-------------.------Distance to nearest lot line----------------- <br /> ❑ U-� <br /> Size: Diameter------------------ Deptn---------------------------------Number of pits----------------------Lining material---------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation___._...__.-_-___..Lining material____________---_.____.__________-_.- <br /> r ❑ Size: Diameter-------------------------------------Depth------------------------------------------ -------Liquid Capacity----------------------------galso <br /> Privy: Distance from nearest well____ ___________ _______________________Distance from nearest building------ <br /> ❑ Distance to nearest lot line------ ------------- ------------------------------------------------------ -------------------------- ------------ <br /> Remodeling and/or epairing (deste)L" ll' ��k- --- -- -C! Q,- �`� G` r <br /> (�S.d - K <br /> ----- --- -- <br /> ' ----�-- ------- ----- <br /> _ - � - <br /> (� _ _ <br /> -. <br /> ! herel3y certify that 1 have?repared this application and that the work will be done in accordance with n aquin County <br /> ordinances, State 1 rules and regulations the San Joaquin Local Health District. <br /> C._..� Contractar) t <br /> (Signed)----•---------------------- -- -- --------------------------- --------- ------------------------------------------- <br /> By:______________________•_____...__________.....__________.______________. ____.____ __. __ _ _- ___--____ ______________._{Tale)__ _fir__:�.�•>��-.__�_ '_-�_.._.____ <br /> Plot plan, showing size of lot, location of system in re6i n to wells, buil�gs, etc., can be pla ed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> 1. <br /> APPL'ICATION¢;.ACCEPTED BY --------•--------------••-------------------- DATE----- ------- ------------------------ <br /> -- - <br /> REVIEWED BY'-----:---------------------- *;-b-p----------------------------------------------- <br /> DATE---------- - O'I ` ` , <br /> BUILDINGPERMIT ISSUED------ ------------V------------------------------- ---------------------------------------.-------- DATE--------------------------T------- ----------- ------------- <br /> Alterationsand/or. recommendations:-----------------c----_-r ------------------.2t----.-------- _____=-- ,a—___-_---_ ___________--___-____________________________________.____________---_ <br /> ------•--------------------=--•--- --------------•- ----------------------------------------------- --------------••-------------••---------•• ---•--------------•------------------- ---------•---;------•----------------- <br /> ------------------------------- ------------------------------- <br /> ----------------------- <br /> --------------------------•-----------------------=- ----------------------------------- '........ ----------- ------------------------------------------------------------- -- ----------------------------------------------------- <br /> FINALINSPECTION BY:------------------------------------------------- ------------- 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 10-52 Revised W-2100 4- 1 <br />