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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate] <br /> Date Issued �Y-(a•:•I--5 <br /> 3 ' <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-__----_.__ _,�- <br /> .......... f....... <br /> � <br /> - <br /> ' Owner's Name--------------•-------•--- -- - -+-•------ -- �-- -=P� - ��a�--�'"-J .+ <br /> ---------------------------- <br /> --------------------------- <br /> --- <br /> ----------- --- ---- -- - ------- <br /> Phone------ <br /> Address---­------------- ...... <br /> --------------- <br /> -------- <br /> Contractor's Name----------------------- <br /> - --------- ------- I <br /> p ❑---------- - <br /> I----------- ------- ----- -------------------- Phone--------- <br /> Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ Motel p of J t <br /> Number of living units: ___ Number of bedrooms --?-- Number of baths of size -------------- <br /> .---- 5--- -. __ a ❑ i <br /> Water Supply: Public system ❑ Community system ❑ Fr v�a-tel❑ Depth to Water Table -------- ff. <br /> #� Sand'YLoa El Clay Loam'❑ ClayE]� ❑ Adobe Hardpan El <br /> Character of soil to a depth of 3 feet: Sand El Gravel <br /> Previous Application Made: Yes ❑ No ❑ New Construction: es © No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: , � <br /> k <br /> (No septic Tank or cesspool permitted if public sewer is available within 200 feet. <br /> Septic Tank: Distance from nearest well-----------------Distance om f undation_--------- <br /> " Material------------------ t <br /> No. of compartments--------------------------Size_---�_-- _ --------Liquid depth--------------- ---------Ca acit <br /> Disposal Field: Distance from nearest well. SQ .DistaJ from foundation------ � . <br /> ,Distance to nearest lot line_--_-_.---__---- (� ' <br /> Number of lines:.--------�j---------- ---- Length of each I�ne- -O3_- Q --20 Width of trench----�'�- ----- <br /> Type of filter material-_�p- --__--Depth f filter material-----� ! Total length-------•/-Zo-- <br /> Seepage Pit: Distance to nearest well-__------------------Distance from foundation---:__________-_-_-.D an a to n 'lot line---- <br /> ❑ Number of pits ----------------Lining material-- ' <br /> --------Size: Diameter-----------------------Depth ------------------------------- <br /> Cesspool: Distance from nearest well--------------- -Distaril from foundation--------------------Lining{material__--__---____----_-_---_--_-_ - - <br /> ❑ Size:- Diameter----e` ------------- ------Depth <br /> Privy: Liquid' Capacity- ---------- -------------gals. <br /> Distance from <br /> li <br /> areswe -------------------_----..-- <br /> _____-------Distance fron-s•nearesfibuildin <br /> g <br /> I <br /> Distance-#o nearest tot-lme------�---°-___._- ----. •..�.,� .,..�.. <br /> -------- - <br /> Remodeling and/or repairing fdescr;be)----------------------------------- ------------------------------------------------------------------------ <br /> ... <br /> l tf <br /> ---------------------------•----- ; <br /> - --------------------------------- -•------------•------------------------------------------------------------------------------------------------ <br /> `' F--•---------------------------•------•- f'` •: = i <br /> ! hereby certify that ! have prepared this application and ftllat the work will be done in accordance with San Joaquin County ; <br /> ordinances, State laws, and rules and regulations of the San J#oa uin Local Health District. <br /> Si ned ,_ --� - P-- 0-1 <br /> - <br /> (Signed)-,7 g } - ------- (Owner and/or Contractor) <br /> ------------------------ <br /> s R* Y <br /> _-• `- - »,.�-Title--; ----------;�---- -:-------------- 1 <br /> (Plot plan, showing size of lot, location of system in relation to Jes;`buildings, etc., can be placed on reverse side). <br /> FORD EPARTMENT HSE ONLY <br /> APPLICATION ACCEPTED BYpi <br /> -- -- -- ------ � _ - , <br /> ------ DATE_ -.- <br /> EVIEWEDBY -- --------------------------------------------'------------------- ------ DATE <br /> BUILDING PERMIT ISSUED _ --4----- -----•-------- i------------••-------------------- DATE------ <br /> ----------------- <br /> ------- <br /> Alterations and/or recommendations:------.---------------- <br /> ----•-------•------------ -------------------------------•---- - <br /> ------------- ------- ----------+-------------------------------- <br /> -L- -- <br /> FINAL INSPECTION BY:-- Date - , <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 <br /> Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 <br />