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APPLICATION FOR SANITATION PERMIT Permit No- ---------- --- -------- <br /> (Complete in Duplicate) T3 <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 <br /> application is made in compliance with County Ordinance No. 549 1 <br /> 10 <br /> JOB ADDRESS AND LOCAN.4­,4---- ------- - -- --------- -- -------------- ---AO------ ----------------------------------------------------- <br /> 1!4) <br /> Owner's Name------ -------..... . ---- ------------------------------------- Phone---------------------- <br /> x <br /> Address <br /> hone----------------------Address------------- --- ---- - - ----------- <br /> ------------------ ---------------------------------------------------------- <br /> ------- --- <br /> Contractor's Name__--- ---tj------ Phone----------------------------------- <br /> Installation will serve: '-Residence E]..-;A�pKarent-House-E] Commercial F] Trailer Court [3 Motel Ej Other El <br /> er of bedrooms <br /> WL er of bedro Number of baths .-./- Lotrsize ---- ------1� <br /> Number of living units: /, ' _ ­ ,r ---------------------- <br /> Wafer Supply: Public system Community system 'Ej Private L] Depth to Water Table ----0-/f f. <br /> Character of soil to a depth of 3 feet: (Sand P^, ravel E]' Sandy Loam lay Loam ❑ Clay E] Adobe 0;-�an Ll <br /> Previous Application_Made: Yes [] No V New Construction: Ye-s No El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer:is availa6le.wifhin 200 feet.) <br /> Septic Tank: f Distance from nearest well-__--__:___..__Distance from,founclafion---------------------Material------------------------------------ ------------ <br /> Fv- No. of com�arfme'hl�5--l-'------'.-.-.-- S-ize-----­----------- ------------Liquid depth----------------- --------Capacity----------------------- <br /> Disposal Field: Distance from nearest weil-------------:---Distance from foundation------------ -------Distance to nearest lot line_________________ <br /> p 9 p p Y----- - - -- - <br /> Number <br /> ine----------------- <br /> Number of lines--------------------------.---:1--Length of each line-----------------------------.Width of trench--------------_-------------------. <br /> �ii Type <br /> rench----------------------------------- <br /> Type of filter material-------*-------------------O.Pepth of filter material-------------- ------Total length__......--------------------------------- <br /> Seepage Pit: Distancef we10/6-"- -'/-/nistance f�WnjoVdation/-mW.'---'-0i,ta ne--/_ <br /> Number <br /> to nearest --- - - ----------- pc, to nearest lot I* ------- <br /> Number of pifs--L4,0t/%,k-------Lining material...(e& --.S:ze: iameter--­-1-------------Depth---.----- <br /> ---------------Cesspool: Distance from-nearest well-'-- Distance from foundation--- -----------L-----Lining material._-_-.__._____.._______.____________ <br /> 0 Size: Diameter---------------------------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. <br /> -r i�v y: Distance from nearest well_..______._______ -------- ----- - nearest-building------------------------------------------ <br /> P Di.5fance from ' <br /> El Distance to nearest. lot line------------------------ ---- - ----- ------------- ---------- --------- ------------------------------------------�)------ <br /> ic'Ta Tank: <br /> Disposal <br /> Septic <br /> Page Pit <br /> Remodeling and/or repairing (describe):---------- --- -- ----- --- -- ----- ------ ---- -- -- ------ ---------- ----- <br /> --- - --- ----------- ---- -------- ------------------------ ----------7­1,7�- <br /> ------------------------------------------------------------------- ---------- - -------------------------- ........ <br /> -------------------------•-------------_,----------------------- ... ............ --- --- ----------------------------•----------------- <br /> -------- <br /> ----------------- <br /> -------------- ------- --------- - ----------------------------- ---------------- ----- --- - ----------- ----- ---------------------------------------------------------- <br /> -----------------------------------------: <br /> I hereby certify that I have prepared Al application and that +he w.ar ill e done in accordance with San Joaquin County <br /> ordinances. State la and rules and regu tions of the San Joaggin Loca ealfh Dilfrict-. <br /> A <br /> (Signed)-- ---------- . ..... n� --- and/or Contractor) <br /> BY -----------------------------------------------------------------mfl el------------------------------------------------------------- - <br /> (Plot plan, showing siz l0 loc ion of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------------------------------------------- DATE-------------- f�/ �c'' <br /> [/ <br /> REVIEWED <br /> ATE--------------- <br /> REVIEWED BY---------------------------------------------- -----------­----------------/V-3 z-------------------------------- --------------- <br /> ­­ DATE------------------ ----------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----------------------------------------------------- ------- <br /> Alterations and/or recommendations:--- ---­­-------------- ------- ---------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> --------------------------------------------------------------------- ---------------------------------------- ------------ ----------*---------------------------*---------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- <br /> FINAL INSPECTION BY:-------------------------- VADate----------------- If ----------------------------------- <br /> ---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manfeba, California Tracy, California <br /> E5-9-2M 10-52 Revised W-2100 <br />