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_ APPLICATION FOR SANITATION PERMIT Permit. No. Af-_�'_L----- <br /> (Complete in Duplicate) `[/� rS <br /> Date Issued _____ <br /> Application 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 Ordinance No. 549. <br />- JOB ADDRESS AND LOCATION___.;� ____L. ___ I �--�______ ___ _ ___ __ .,fes-' -.---------- <br /> ----­---------------------------------------- <br /> PhoneOwner's Name---------- -��`�'f'�� f "� -- -- -------- ------------------ ----------- --- -- ---------------- <br /> AV- <br /> -- <br /> Address-_------------ Z49--- .. ? _ _ �C�"+r-- ' <br /> 3 <br /> Contractor's Name---------------------------•--------------------------------------------------------------------------------------------------------_--------- Phone----------------------------------- <br /> Installation <br /> ---•-- ---•--Installation will serve: Residence E--'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> r <br /> Number of living units: I____ Number of bedrooms __f__ Number of baths I____ Lot size _��_..�_�_� _______________________ <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 ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes E] . No New Construction: Yes ❑ No ❑ FNA/VA: Yes ❑ No ❑ s <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> Septic ank: Distance from nearest we! _�._f______Distance�rom ou d �on_0.1---------- <br /> Material ------ � <br /> No. of compartments_..______ __.Size__ Liquid cl pth_---_ -_ t _-_ d <br /> - ,X- ' _ ;� Capacity <br /> Disposal Field: Distance from nearest well__4-d.-------Distance from foundationt5___.___ _,Distance to nearest lot line--_____._____ <br /> Number of lines____ __________ ________ Length of each line__..___a ----Width Width of trench__ �__`-- <br /> I F <br /> Type of filter materialepth of filter ____.___Total length______�_____- -.---------------------- <br /> Seepage. Pit: Distance to nearest well----------------_---Distance from foundation--------------------Distance to nearest lot line----------------- Q 1 <br /> ❑ Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------Depth----------------------.---------- \ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------:Lining material-_____--___-_______.__.________,____ <br /> ❑ Size: Diameter-------------------------------------Depth------------------------------------- -------------Liquid Capacity---------------------------gals. <br /> Privy: Distance from nearest well _____________________________-------------------Distance from nearest building________.___________________________._. <br /> ❑ Distance to nearest lot lire--------_------------------------ -------------------------------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> 9 <br /> -------------- -•------------------------------ --------' ------ -- <br /> I hore6y certify that I have prepared this application and thaf the work will be done in accordance with San Joaquin County <br /> ordinances, tate laws, and rules and r ulat' ns of the San Joaquin Local Health District. <br /> �� _ _____-___ ( and/or Contractor) <br /> (Signed} • - •- -_ ------- --------------- ------------------ Owner _ <br /> ------------------------------ Title --- �= <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> 911-01FI 'RT,MENT UKE ONLY Q <br /> APPLICATION ACCEPTED BY----- t ----------- DATE----/ •.� --- i <br /> REVIEWEDBY-------------------------------- ---------------- ---------------------------- ------------------ ------------------------- DATE--------------------------- - <br /> BUILDINGPERMIT ISSUED---------------------------------- ------------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations--------------•----•------------------------- - ----------------•-----------------------•--------------------_--------•-•-- --------•----,---------------------- <br /> ----------------------------------------•-----------•----•-------------------------------------------------------------------------------------------------------••--- •-------•--•----•-•----••------------------ <br /> -------------•---------------- ---------------------------------------------------------------------------------------------------------------------------------------------• --------- -------------------------------- <br /> -------------- ------- <br /> ------------- ------------------------------------------- <br /> _._ f <br /> Y4 <br /> FINAL INSPECTION BY-------- -------------- -=-` -- ----- Date l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore $tree+ 814 Nor+h "C" Street <br /> Stockton, California Lodi, California Manteca, California Traey, California <br /> ES-9-2M , Revised 1-57 F.P.CO. – t <br />