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4 <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) 1 1 <br /> �b� Date Issued !C �_.'I_ <br /> Application is hereby made to the San Joaquin Local Health District for a permet to construct and install the work herein describ d. <br /> This application is made in compliance with County <br /> M Ordinance <br /> No. 549. <br /> ION__ / Z,,`�) � 'X , (,t ' <br /> fJOB ADDRESS AND LOCAT = - � . = ---------= ==`- Lc� _r.#,_ <br /> r <br /> ---------------------�-•- <br /> ,s <br /> Owners Name <= ••- ------ ` <�_ ---------------------------------------- <br /> -- . ------------------------------------------ Phone--'----------------------------F---- <br /> Address_.:. � -- ,r 1 :,5 `" ` { '-` :,. � <br /> -- -- --- ----- <br /> Contractor's Name-------------------------------------- ------------------------------------------------------------ Phone__t----------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___ _._ Number of bedrooms __ ____ Number f baths _:_-_-_ Lot size ._ - -_- --_ ----- <br /> 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 W Clay Loam❑ Clay ❑ Adobe ❑ Hardpan <br /> Previous Application Made: Yes ❑ No PJll"New Construction: Yes eNo ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 41 <br /> (No septic tank or cesspool permitted if public sewer is available within 10 feet.) <br /> Septic ank: Distance from nearest well_-i. -----_Distance from fours •tion---jta____------_.Material_---�------------------- <br /> No. <br /> _--- ______No. of compartments- Size-------&_k SY.___ _ -Liquid depth-------- --_-Ca acit _od <br /> l ----- <br /> Disposal Fieid: Distance from nearer well___J_�-._Distance from foundation--__----_0-------Distance to nearest lot I e_-------___-__-_- <br /> Number of lines----------------------------- -- Length of each line----------:O-____ Width of french--------�. <br /> T e of filter material.17-YAC_ _ Depth of filter material--------1.9-_--- Total length----------25�________- � <br /> r Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-__________-_____ <br /> E❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------------- <br />*� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__--_-----.-_____-_-_-----_-.------ <br /> .-. <br />' ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-=--------------------------gals. <br /> istance rom nearer uildi�n--`"�"� �� T""' <br /> Privy: Distance from nearest well g ----------------------- <br /> ❑ Distance to nearest lot line-- ------------------------------------------ ------------------•------------------------------•-------------------------------------------- <br /> Remodeling and/or repairing (describe)---------- -------- -------- ---- - --- --- -- --____-• <br /> -------------------------•--------•--------•---------------- `_�'�t- -------- ----- ` G-(� ' _ _ •-------------------------------- <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 /> (Si ned - fit l,;t.Z&t ' Owner and/or Contractor <br /> 9 :• --------------------------------------------------------------- --------------------------------------( / ] <br /> By:----------------------- V <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 /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- ----------- ------•--•--------------------------------------------- DATE------- L <br /> REVIEWEDBY--------------------------------------------- ------- ---- -------------------- DATE---------------------------------------------------------- <br /> BUILDING PERMIT ISSUED------------------ ------------------- -------------------------------------- ----------------------- DATE <br /> ------------------------ <br /> AlFerations and/or recommendations:----------------------------- -------------------------------------------------------------------------------------------- <br /> ----------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------- ----------------- - ------- <br /> ------------------------------------------------------------------ <br /> -------------- ----------------------------- ----------------------- --------- -- --------- ------------- -------------- ----- ----------------------------------------------------------- <br /> Ile, <br /> FINAL INSPECTION BY:.------- -�--- ----------------------------- Date----------------_ __ ------- --------------------------------------------- „/ <br /> 4 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 Tracy, California <br /> E5--9--2M 8-51 Revised W-2100 <br />