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APPLICATION FOR SANITATION PERMIT Permit No, <br /> (Complete in Duplicate) <br /> Date Issued ___.__ <br /> 4 `22-5 —a(eo-- <br /> Applica4,ion 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. 519. <br /> f <br /> JOB AD RESS ANDILOC TION:_4_----- <br /> -4 <br /> . --- I ---- ---iq__!,--------------4 ---------------------I--------- <br /> Owner'sName------- -- Phone + <br /> r.� a .� <br /> Address------------------- 1C_!! f f- ' <br /> ---------------------------------------------------------•----------------•----.. <br /> Contractor's Name-------- •---------------- 6--------•-•--------------------------- ----------------------------------------------------------- Phone_-------------------- <br /> ------------- <br /> Installation will serve: Residence ®Apartment House ❑ Commercial ❑ Trail,fi,, Z. ❑ Motel ❑ Other <br /> Number of living units: __�____ Number of bedrooms _- Number of baths _.�'Lo$'size _�_t�_�---�--�- ��_�-_- <br /> -------------- <br /> Water Supply: Public system❑-"Community system'❑.._Private' /Depfh't 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 ❑ No New Construction: Yes No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: , <br /> p (No septic tank'or cesspool permitted if public sewer isavailable within 200 feet. <br /> Se'f' frank: Distance <br /> ofi of Com artme nearest well Dista ce from f u dat' ____ Mate ial6�t_._ _____----- <br /> pp <br /> P s ` Size .__`_ I -b---- squid depth--------- <br /> Disposal <br /> -----Disposal Field: 'Distance from nearest well� __.______Distance from foundation--I --____�"1'�'�`Distance to nearest lot line <br /> __. .. <br /> Number of;lines___._____:_. . _s ___.____-Length of each line------ Width of trench--------- <br /> Type f�----- --..__ �------•-- � <br /> Type of Cff er mate°ria �' opth of filter material_ �_ ______-_-Total length____________ /__ _______._. <br /> s .... s —,� <br /> Seepage Pit: Distance to nearest well______________ _Distanceyfrorii•foundsfion ______.Distance to nearest lot line----------------- <br /> e <br /> Number of'pits------- ---------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------- <br /> ------------ <br /> Cesspool: Distance from nearest well------------------Distance from foundation--------------_____ Lining material_____.____-________.___--______.____. <br /> ❑ Size: Diameter--------t:____-_:-- <br /> -----Depth---------------------------------------------------.-Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well---_...----_____ _____________________________Distance from nearest building____-_______-_______________ <br /> ----------------- -------- <br /> El Distance to.nearest�lof:line------ ------- ---------------------T=--------•--------- <br /> -------------------------------------------- <br /> Remodeling and/or repairing (describe)--------------- <br /> --------------'----------------------:---- <br /> a --------------• --------------------------••--••---------------------... <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 /> IS� ned I � <br /> -g )--------s-----�----j- --- -- ---x�- . �--� ------------------------------------ ----------------(Owner an Contractor) <br /> bY� ----------•---------------------------------------------------------------------- ----- Title)------------------------------ --------------------------- <br /> (Piot plan, showing size of lot, location of sy-sfei in relatiori'fo wells', biiildings,etc.;can'be placed-on reverse side- - - <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ___------- <br /> REVIEWED BY-------------------------------- ----------------------------------------- <br /> - - ----------------------- <br /> DATI= �'_______________________ <br /> - -----------•--------------- <br /> `.---- - -- ---- --------------- -------- __� <br /> -------------------------------------�-DATE---9�------------------------------ <br /> BUILDING PERMIT ISSUED DATE--------9A-------- <br /> Alterations andpr..re�mme dations:__--_�-------------- _______-'____.__-- -- WN <br /> ----------1 , 1 f - au:_,- <br /> ---- <br /> _ - ` r -�`g�'-•-•-- _h -- -F, ------•--------•---------------------------------------••---------- <br /> ---------- ---------------------------------------•---•-----••------•-------------- -------------------------------------------- <br /> ---------- - <br /> ---------•-•---------••-------------------•----------- ------------------------------------------------ <br /> - -------------------------------------------------------- <br /> ------------------------------ <br /> ------------------- --------------------------------------- <br /> L <br /> FI NAL INSPECTION BY:- _Z. _:.._-_ __ / Z� A ]- <br /> ---------------------- ate----=----- ----= ---- <br /> * SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street .300 West Oak Street 132 Sycamore Sfree+ 614 North "C' Street <br /> S+oek+on, California Lodi, California Manteca, California Tracy, California <br /> � 5 <br /> '-9-2M Revised W-2100 # �' <br />