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APPLICATION FnE`: SANITATION PERMIT Permit No. __ <br /> - --"- <br />' " <br /> (Complete in Duplicate) Date Issued __6,cppp//-�Q/`�4 <br /> dye- Otv- z! /// <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 corinpliance with County Ordinance No. 549. V4149e <br /> JOB ADDRESS AN£ 7L�C�A,r TsIcO aN �N <br /> Vi ; 3-J.�-�a �c-k--�Sc�te.Froe------------------------------------ <br /> Owner's <br /> -------------------- -------------Owner's Name- - -LC Y <br /> ' <br /> Address----------�1_ r ------------------------------ <br /> ,..�----�'-'c-._moo--'-�-'----- -rrc�1-------�-------- ------------ ----- <br /> Contractor's Name--------------- ----------------------------------------------------------------------------------------------------------- --- - -- -------------------- Phone----------------------------------- <br /> Installation will serve: Residence 14 Apartment House ❑ Commercial ❑ Trai4er Court ❑ Motel ❑ Other ❑ <br /> Number of baths ---1--- Lot size __-�-�Q- -+t-2-� -------------------------- <br /> i <br /> Number of living units: ---I---- Number of bedrooms __ ; <br /> Water Supply: Public system ❑ Community system '❑ Private ® Depth to Water Table _a".3- 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 0 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.) <br /> Septic Tank: Distance from nearest well---16y.....Distance from foundation____`4�_______.Materi�l�_Ctksl_G�'1° <br /> No. of compartments-------------a----- --Size----ii xX_A/---------------Liquid depth------'v--------------Capacity----•-------- --------- <br /> ,�6 Distance to nearest lot gine___ ___ <br /> Disposal Field: Distance from nearest well----�+�_-_-Distance from foundation____ __ _____"" , � Ile L <br />} �( Number of lines--------------/----"--------``----Length of each line-------1-z0-------------Width of trench------2_1------------- <br /> Type of fi{ter material Gr4ee_J----Depth of filter material_-_.__,�"-------------Total length______ _�--.--------- <br /> Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line----------------- LN <br /> ❑ Number of pits----------------------lining material------------------------Size. Diameter------------------------Depth--------------------------------- y <br /> �l <br /> Weil.............. <br /> __Distance from foundation <br /> El <br /> material________________________ -" <br /> Cesspool: Distance from nearest als. <br /> ElSize: Diameter--------------------------------------Depth---------------------------------- ------------._Liquid Capacity--- --_----------- ---g <br /> _- .. - _ <br /> - - —~ ____-_- _Distance from nearest bu2i- <br /> r Privy: Distance from neares# well------------ ----- g----------------------------------•----- m <br /> ❑ -------------------------------- 'r( <br /> Distance to nearest lot line----- -------------- ------------ -------------------------------- ----- <br /> Remodeling and/or repairing (describe)-------------------------------------------I--------- --------------------•----------------------------•------•--- <br /> ---- --------------•------------------- <br /> ------------------------I-------•-------------------------- <br /> _------------------------- h <br /> - --------------•--•------- ----------------------------------- � <br /> ----------------------------------------------------------------- <br /> --------------------------------------- <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 /> ( C tact ) ' <br /> (Signed) O wner and/or on r ar <br /> Tale <br /> By:_ -NIA1 <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_-__-_._ ___" ---------------------- <br /> DATE <br /> ---------------------------------------- <br /> REVIEWEDBY------------- ---------------- ----------------------------------------------------------------------- DATE----------------------------------------------------------- <br /> BUILDING PERMIT ISSUED---------------------------- - --------------------------------------- <br /> DATE <br /> Alterations and/or recommendations---------------------- ----------------------- <br /> ------------------------------ <br /> ------------------•---------- <br /> -------------------------------------------------------------------------------------------------- <br /> ---•---------- ------------------ ------ <br /> Date_--�-- -----/- .�----r�----------�--------------- <br /> v ' <br /> FINALINSPECTION BY:___-- __"--- -------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ! 132 Sycamore Street 814 North "C" Street <br /> 130 South American Street 300 West Oak Street Y <br /> Stockton, California <br /> Lodi, California Manteca, California Tracy. California <br /> J <br /> ES-9-2M 8-51 Revised W-2100 — - _ <br />