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� ,I Permit No. p �r <br /> APPLICATION FOR SANITATION PERMIT -`---l- [_--•--•--- <br /> (Complete in Duplicate) Date Vrkrein <br /> - `r ~ <br /> Applica+ion is hereby made to'the San Joaquin Local Health District for a permit to construct and install thewscribed. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION--- 02 Q-� '{ e------ <br /> t ---------------------------- <br /> Owner's <br /> _._____----`--------------- <br /> 1----- -------------------------- PhS7 --------- <br /> Address <br /> -_�_ <br /> Owners Name-------- --- - - -- -- ------------------- -A----- ---- •------ - - -- ---------------- --.:,- .. <br /> Address------------------------ ----------r '------- --------- 1q_- __-----------------------------------------------•------------------------- ---------------------. <br /> Contractor's Name-------- -------- -•--------------------------------------------------------------------- Pone-4---- &/_a__ <br /> Installation will serve: Residence/2--"Apartment House E] Commercial ❑ Trailer Court E] Motel El Other E3Number of living units: _-1--- Number of bedrooms _ -_ Number of baths _=__C__ Lot size �_____________________ <br /> Water Supply: Public,syste,m'EF/Community system ❑ Private ❑ Depth to Water Table _,__Q ft: <br /> Character of soil to a depth of 3 feet: Sand Ej, Gravel ❑ Sandy'Loam❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑. No New Construction: Yes ff"No ❑ ( I <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: Y 3: <br /> (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic ank: Distance from nearest well___J` _0_r__Distance from foundation___---0__--------Material___�._ _________________________ <br /> No. of compartments-----a.-._-_ �� .,Liquid depth---- -�- --- -- Capacity--- <br /> QO___ <br /> it � 9 <br /> Disposal. Field: Distance from nearest well---�d._____Distance from foundation--------------------Distance to nearest lot ling___,!_________ <br /> [y� Number of lines---------------/----- ----- _ Length of each line--------- Width of trench---- `�-------------------- <br /> Type of filter material_l :__ .__Depth of filter material-----/f - -----Total length-----------------------------______________ <br /> Seepag Pit: Distance to nearest well----_ L_0 --------Distance from foundation_____ �?______.Distance to nearest lot line___ ______ Q <br /> Number of pits--------)-----------Lining material__-Lt .Size: Diameter__ _,3_�-________.Depth_____ ____-_____ <br /> ------ <br /> Cesspool: Distance from nearest well-------------_---Distance from foundation----------------------Lining material-------------------------------------- <br /> ❑ p ------Liquid Capacity----------------------------gals. <br /> Size: Diameter----------------------=--- - ---.De th---------------- - ------------------------ <br /> Privy: Distance from nearest well---------------------------------------------g---Distance from nearest building__{_._______________________________.._. ' <br /> ❑ Distance to•nearest,lot line--------'-------------------------------------- <br /> hRemodeling and/or repairing (describe):------ -----------------------------------------------------------------------------*_.: ...............-•....... ------------------------------------- I� <br /> ------------------------------•---------------------------------------------- <br /> ----------'------------------------------------•---------------------•-------------------------------------------------•--•------------- ------------------------------------------------------ <br /> '-------------------•---- ---------------------------------•--------....----------------------------------•------------------------------------------------------------ ---` <br /> 1 hereby certify that I have prepared this application and +hat 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) ----------- -------------------------;------------------------------------------------fir and/or Contractor) <br /> By:----------------....... - - '-------------------------•--------------------------------------•---------(Title)------ ------ ------- - ----------------•- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> F . <br /> ~ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- DATE --------------------------------------------------- <br /> REVIEWED BY-------- ----- ----------•--- DATE._ --------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------- ------------ DATE---------le------------------------------------------------ <br /> Alterationsand/or recommendations------------------- --------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------•-----------------------------------------------------------------------•--••----------------------------------------•- ------------------------------------- <br /> _ -•--- ----' ------------------------------------ _ <br /> FINAL INSPECTION BY-.:--- /!.!'7-- - Date- =s <br /> - ------------------------- <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 />