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APPLICATION FOR SANITATION PERMIT Permit No. - <br /> (Complete,in Duplicate) <br /> 0 Date Issued ----- <br /> gA <br /> plica+ion is hereby made to the San Joaqu-in'Local Health District for 6 permit to consfr. ct and install the work herein described. <br /> This <br /> application is made in compliance with County Ordinance?N . 549. <br /> --------------------------------------------------I;---------------- <br /> JOB ADDRESS AND LOCATION________._ --- - ----- -- - ➢--- - ---------- <br /> Owner's Name-------------- - -- ---------------- ---------- ---------------- - --- 0 ---------------------11--------------- <br /> Address__.--------------------------•- ------- -------7---------- -- - -- -------- -- -- ----------- --- ---------- <br /> Contractor's Name--------- ---- ------- one. <br /> i ." IF <br /> Installation will serve: Reside'nceo partment House E] Commercial' railer-Court ❑ Motel Other E] <br /> Number of living units: ------ N - Lot size _d 81 <br /> ber of bedrooms -------- Number baths 4---- ------ ----- ------------------------ <br /> �1_1�U_ <br /> Water' Supply: Public system: Community system E1,4rivate E] 'Depth to Water TablOw'-ft.- <br /> Chara"cfer of soil to edepfh of 3 feet: Sand E] Gravel [I Sandy Loam ❑ ay Loam ❑ 'Clay'D Adobe Hardpan [) <br /> Previous Application Made: Yes Ej No E] New Construction: Yes e No Ej <br /> 1� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No�sepfic tank or cesspool permitted if public sew is available within 200 feet.) <br /> aterial-----0 <br /> Septic Distance from.near6st well istance�rom-�undati�iq <br /> �depth__M���____. <br /> 141t- ------- LS44No. of cdmpartmenfl--le"------------ ize--- < ,4------- .6a acity--//..H W <br /> Distance from nearest well-A0141w-ir tion-- ------- e-----------Z--. <br /> Disposa�,Kld -_____Distance from founda _/"�--------Distance to nearest lot ------ <br /> Numb lines Length of each line_-- 0.1.4--00- Width of french---et`_ <br /> Number of ne------4 __ I <br /> 1!r &x, - -ZI----- ----------- 1�\ <br /> -0 Depth of filter material----4_7---------Total length----- ---- --- ------------ <br /> Type of filter mafer-ial-Z '-/If <br /> See Distance to nears I I AD_��-------Distance from fovnd.ation----4�.__-11___.Djstgnce to nearest lot line -------- <br /> ,51 we Q -1; <br /> Dumber of pits._&V__#-------Lining material-1!"-'1- 5 Diameter-----V--- Depth--------*_�.-47--------------- <br /> Cesspool: Distance from nearest well-----------------Distance from�fo Yd,�tion - -----------------Lining material__.___._-____________.__________._._. <br /> Size: Diameter-------------------------------------------------Depth-------------------------------------- -------------Liquid Cap ------- .1s. <br /> D acity------------------I g <br /> -A."w_f <br /> rivy., ....Distance from nearest building------------------------------------------ <br /> ET Distance to nearest lot line--------------------- ----- - -- ------------------------------------- .... <br /> - ------------------------ <br /> Remodeling and/or repairing (describe)--------------------- ----------- ------- ----V----- - ------------ ---- - <br /> ---- -- ----------- <br /> ---- ----- -- ------------••--------•---------------------------- <br /> - ------- - --------------------- <br /> ---------- ----------------------------­,­--------------------------- -- ------------- ----- -- ---------------------------------------------------------- ----------. ........ ------ ----------- ----- -- -------------I--------------------------------------------------- ---------------- <br /> - ------------------------------------ --1-------------------------------------------- -----1.1--------------------------------------------------------------------------------------------------------- --------------- <br /> I hereby certify that I have prepared this ap ication and that the work will be done in accordance with San Joaclu n County <br /> ordinances, State laws, an rules and regAptions of the San Jolau.,n Local Health Disfri f <br /> 's <br /> )ef; X Af .4 <br /> 4 <br /> j-- ----- - -------- ------ (Owner nd/or Cbritiactor) <br /> (Signed}-----------0 ------ <br /> By:----------e! <br /> .. ... -- -- ------ ------ -------------------------------------------------------I--------(Title)- -----j?- --------- <br /> (Plot plan, showing size of to+,-location of system in rotation to wells, buildings, etc., can be placed on reverse side)..' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__<�------------------------------------------------- ------------------------------------------- <br /> DATE <br /> . . - DATE �-- <br /> -------------- . <br /> ------- <br /> REVIEWEDBY --------------------------------_---------------- -- DATE - . ------- - <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------- ------ DATE -IJ>-- ------------------ 3 <br /> ecommen -- ------------- --------- --------- ---------------------------------------- <br /> -- -------- --------------------------------------- <br /> Alterati s nd/,or cl�ifions:----------------4----------------- ----------- ------ <br /> --------W- ----- �,� X -- ---- -------------------------------------------------------------I........[---------- --------------------------------------------------------- .------------------ -- ------------- <br /> C- ------------- ------- <br /> - ------------------------------ <br /> -------------------------------------------- ------- --- ­ --------------------------- ------ ----------- ---------------------------------------------- --------------- <br /> FINAL INSPECTION' BY:---- ---- ------------------------------------------ Date---------t- ---- ------- ----------------- k-------- ---- - <br /> -------------- <br /> -- I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> l <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Sfock+on, California Lodi, California Manteca, California Tracy, Californie.i <br /> ES-9-2M Revised W-2100 <br />