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4 <br /> APPLICATION FOR SANITATION PERMIT 10 <br /> Permit No. <br /> (Complete in Duplicate) (/dIaltPissued ------- <br /> 7 <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 application is made in compliance with County Ordinance No. 549. <br /> ..,Z20 <br /> ---------------------- ----------­­--------- -- ---------------------------------------------------------- <br /> JOB ADDRESS AND LOCATION--------7 -- --------&-,-_` (I," h, I C ---- <br /> Owner's Name------Mi-=------- -------------------------------------------------- --------------------------------------------- Phone------------------------------------ <br /> Address,.--------------_---------1_��........ ---------- ----------------------------'--•--------------- ------------•-•------------------ ---------------------------------------- <br /> Contractor's Name-------------------- 0- ----- -------- Phone-------------------------- <br /> Installation will serve: Residence [A Apartment House 0 Commercial L] Trailer Court L] Motel Ll Other/L] <br /> Number of living units: -------- Number of bedrooms ---3.. Number of baths -__M_-._ Lot size ------- -------------------------------------- <br /> Water Supply: Public system El Community system El Private Z Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand L] Gravel 0 Sandy Loam 5d Clay Loam El Clay E] Adobe E] Hardpan O %A <br /> Previous Application Made: Yes E] No New Construction: Yes K No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-------7,7----Distance from foundation-------/0--------Material--------4M_ _r_y-,f <br /> No. of compartments------------2-----------Size-------Cj_y 5 --_3----Liquid depth-----------$' __.-----Capacity------ ---------- <br /> x <br /> Disposal Field: Distance from nearest well- ..--7.1------Distance from foundation--------I- -_f_--Distance to nearest lot line_'____5 -------- <br /> Length of each line---------j_.0__., Width of french-- )/,///­------------- <br /> Number of lines__________________3------------- j_.0__.,,______.Width ----------------;P <br /> Type of filter material------- ---Depth of filter material--------0 ------____Total length---__---I---�_V_____________________ <br /> Seepage <br /> --------------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation------__---------Distance to nearest lot line----------------- <br /> El Number of pits----------------------Lining material-----------------......Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from founclaflon--------- --------- Lining material_-__--_--.--__-----____---____-____. <br /> ❑ <br /> aterial------------------------------------- <br /> El Size: Diameter----------------------------------Depth--------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well_---------------------------------------------Distance from nearest building--.------.__-----_-___--__-_--.-__--_-.-_. <br /> ❑ <br /> uilding----------------------------------------- <br /> F1Distance to nearest lot line-------------- ------------------------------ ---------------------------------------------------------------------------------------------- <br /> ----------------------- <br /> 4 -_ <br /> Remodeling and/or repairing (describe)----------------------------------------- -------------- �1_ ­­--------------------------------------------- <br /> ------­_­--------------------­-----------------------------------------------------------------------------------­-------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------1-------------------------------------------------------------------------------------------- - <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 /> ---------------------------------- ---------- - <br /> Signed --------------------(Owner and/or Contractor) <br /> ( )--------1, ------ ----------- ------x <br /> By-------------- ---------------------- --------------------------------------------------------(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 <br /> --------------------------------- DATE_--- ---- <br /> ------------- ----------------- <br /> - ------- - ---------- <br /> ------------------------- DATE �--- - ------ <br /> REVIEWED BY------------------------------------ -------------------------------- ---------- <br /> BUILDINGPERMIT ISSUED-------------------------- ---- ---------------- -----------------------------------r---------- DATE-----------------------------'-'--•------------_------- <br /> Alterations and/or recommendations---- ------ ----- ----------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------- ----I -------------------------- ----­--------------------------- ---�I----------------------------------------------------- <br /> -----------------------------------------------------------------------­­......... --------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------- ----I---------------------------------------------------------------------------- <br /> ----------------------------------------------------------- <br /> ---------------- ----------------------------- ------- ------------------------ ------ --------------------- ---------- ------------ -------------------- --- - - --------------------------------------------------- <br /> FINALINSPECTION BY:.._�-------------- --------- ----------------­........ ------ Date....- --------------------------------------------------- <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 /> F&---9-2M 8-53 Revised W-2100 <br />