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APPLICATION FOR SANITATION PERMIT Permit No.4�1_7_____ <br /> IZ (Complete in Duplicate) <br /> p- TPate,Issued --- <br /> /' , �� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct a, install the work he in described. <br /> This application is made in compliance Cou ty Ordin ce No. 549, <br /> JOB ADDRESS AND LOCATION <br /> - -------- <br /> _L_-- ----- - - - ------- <br /> Owner's Name.- <br /> - <br /> ------------- <br /> -------------------------- <br /> --- --- ------------ ------ ho e- <br /> Address.......... --- <br /> Contractor's Name-------------------- ---- - - ----- --------------------------------- ------------------------------------------------------------ Phone.3- <br /> Installation will serve: Residency. ' Apartment House ❑ Commercial F] Trailer Court El Motel L] Other E] <br /> Number of living units: --- Number of bedrooms Number of baths ,-/----- Lot size <br /> Water Supply: Public system ❑ Community system E] Privat e8l"Depth to Wafer Tabl,,P-,? ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel [I Sandy Loam Clay Loam 0 Clay Adobe E' E] <br /> E'3 Hardpan A� <br /> Previous Application Made: Yes 0 No New Construction: Yes E• NAj-- <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) <br /> Sepfic Tank: Distance from nearest well---------------_Distance from foundation--------------------Material <br /> No. of compartments----- ---------- -----.--Size-..----------_--_ <br /> ------------------------Size--------------------- ------ Liquid dep <br /> —_X)p --------------------------Capacity re �;- / <br /> /' <br /> Disposa� Fiel&.,/ Distance from nearest Distance from foundation -----Distance to nearest lot line---- -------- <br /> Number of lines__-__----/------------:_j......Length of each line----- , --Y�------------Width of trench­--e4�_ <br /> Type of filter materia Depth of filter material---11,9V-'-'--'-_.-Total length-__----��Z 4',2 <br /> --------- -- --- ---------------- <br /> Seepage Pit: Distance to nearest well_----- ______-._Distance from foundation-------------------.Distance to nearest lot line--.--.-_-------I.- <br /> El Number of pits-----------------------Lining material----------------------.Size: Diameter---------------------- Depth------------------------------- <br /> Cesspool: <br /> epth---------- -------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-- --------- -------Lining material--.___--..-.--- -----------.__..---- <br /> El Size: Diameter-----------------;----- --------------Depth----------------------------------------------------Liquid Capacity----------------------------gals <br /> Privy: Distance from nearest well---------------------------------------------11�--Distance from nearest uilding------------- --------------- -....... <br /> --------- --- --- <br /> Distance to nearest lot line------ ------------------------------------------------------- <br /> 0 N- <br /> ------------------------------------ -i <br /> Remodeling and/or repairing (describe):- <br /> 6;5_ <br /> -11, - i� --- -- --------------------------------------------------------- <br /> ------------------------------------------------------------- -­------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------I------------------------------- ---------------------------------m------------------------------------------------- <br /> ------------------------- ------------------------------------------------------------------------------------- --------------------- -------------- ------------------------------------------------I---- -------- <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun+yl. <br /> ordinances, Sto+e-iaws, Xa.nul and regulations of the San Joaquin Local Health District. <br /> (Signed)------ �__e------ ------------------- ----------------------- -------------------------------------------------------------------------- -_(Owner and/,orpontractor). <br /> By:-------------------- .......... ,U. ---------------------- ---------------- ------ ------------------------ <br /> Y• (Title)---- <br /> I --------------- <br /> ---- ------ <br /> (Plot plan, showing siz Of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side) _l/ _: <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------ ---- -------------------------------------------------------- DATE--- ____77 <br /> REVIEWEDBY---------------------------------------- -------------------------------------------------------------------------------------- DATE.--------- <br /> BUILDING PERMIT ISSUED.----------------------------------------------------------------------------------------------------- DATE <br /> Alterations and/or recommendations:---------------------------------------- ---------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------- ------------------ ----------------------------- ------------------------------------------------------------------------------------------------------------------ <br /> ---------------------------I---------------------------------- -- ------------------------------------ --------------------------------------------------------------------------------------•----------------------•------:----------------------------------------- --------- ----------------------------------------------------------------------------------------------------------------------------------­ <br /> ------------------------------------------------------------------- - <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:.---- -1------------------------------------------- Date - -------/� <br /> A. ? - ----------I -------------------------------------------------------- <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 Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 <br />