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//Y <br /> APPLICATION FOR SANITATION PERMIT Permit No.c �x- <br /> (Complete in Duplicate) <br /> Date Issued/__-_ <br /> '�( /Do —[7f <br /> Applica--ion is hereby made to the San Joaquin Local Health District for a permit to construct and install he work 1�er0 described. <br /> This application,is made in compliance with County Ordinance No. 549. <br /> �t�p73z . f r 644-L) <br /> JOB ADDRESS A�LQTI10N__iA �U --- __Owner's Name---- Gy Phone -, �0-3 <br /> Address ... �O�Z'-------------••-•-•----------------------------- --------------------------------------------------------------------------------•------------ <br /> �,,fi,, �j--- <br /> Contractor's Name-------PI �-----J1 •------------------------------------------------------------------------------------------- Phone?�v '------ <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial V3 Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size _--_ ---- -----------------_----_ <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table y _ ft. + <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe®/Hardpan ❑ <br /> Previous Application Made: Yes ❑ No gr­New Construction: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> {No septic tank or cesspool permitted if public sewer is available within 200 feet.) i <br /> Septi Tan : , Distance from nearest well-----------------Distance from foundation-------------------Material----_---__--_..-----.-__-----_-----.__--------. S i <br /> I <br /> No. of compartments----------------------.--Size--------------------------------Liquid depth--------------------------Capacity----------------- t �l <br /> Disposal Fiel : Distance from nearest <br /> well-1®4-.__'tDistance from foundation_._-3 <br /> "r� <br /> _..____.Distance to nearest lot-l-i-nes`NO, <br /> Number of lines----__.-_ - ----- ---------------Length of each line----- of french....�y- --------•---------- <br /> Type of filter material---J^•_ _O.0k----Depth of filter material----. --------Totallength <br /> . <br /> length___, �------------------------------- - <br /> Seepage Pit: Distance to nearest well_/0A_1....------Distance from foundation---3-��__------Distance to nearest lot linej_.2v"4_ <br /> El� Number of p;ts_____/-------------Lining mate ria / iC�'Size: Diameter...... -6-��-------Depth------.2.5----------------- ' <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-__-_.-------------_------___-_.-_. <br /> ElSize: Diameter----------------- ------- -----------Depth----------------------------------- ----- ----------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ QQ <br /> ❑ Distance to nearest lot lire----------------- ---- ------------------------------•---- <br /> Remodeling and/or repairing (describe)------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---•---------------------------------------------------------••-----------------------------------------------------.---------------------------------------- •-------•---••-------------•------------------------ <br /> ------•----••-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- • <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)---------/?Ol"._--__1/7_ o A- <br /> - ----- ----------- --------- -------- r Contractor] <br /> - - -- - - - - ----- --- <br /> --------------------- --------------- ------ -- ---- ------ <br /> gri----_-------------------- ----- ----- ----------------------------------------------(T;+le) <br /> (Plot plan, showing size of lot, location of syste in relation to wells, buildings, etc., can be placed on reverse side. <br /> FOR DEPARTMENTrUSE ONLY <br /> APPLICATION ACCEPTED BY-------------------------------------------------- -'!- -- DATE----- f <br /> REVIEWED BY - ---I�-S-�-----------------------• ------ DATE------ ----------- <br /> BUILDING <br /> � -.-.. <br /> BUILDING PERMIT ISSUED---------------------------------------------------------•----- = -- --- -----•-- DATE <br /> Alterations and/or recommendations--------------------- <br /> ;; <br /> ---------------------------------------------•--------------------------------------------------------------------- <br /> -----------------------•------•----------- <br /> ------- ---------4------ ------------------------/-------------------------------------------------------------- <br /> FINAL INSPECTION BY--------- ------------•---------------------- ------------------ Date-------- ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street .300 West Oak Street 132 Sycamore Sfreet, 814 North','C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ; Revised W-2104 <br />