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3 } <br /> APPLICATION FOR SANITATION PERMIT Permit Nor . <br /> lh I (Complete in Duplicate) -� <br /> ��j ��� � D to slued _1'�•_�__��•.;! <br /> E � 17 �G <br /> `Application is hereby made to the San Joaquin Local Health District for a permit to construct and ins}all the work herein described. <br /> [flys application is made in compliance p e with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION---------74,i ------- <br /> __0 �_ 1 <br /> Owner's Name------ =J � (✓-------- ------ ------------------ Phone----------------s <br /> Address---------------------------- \ <br /> Contractor's Name J------------------------------------- Phone ._ <br /> ---- - ---- - <br /> Installation will serve: esi ce par me ouse mmercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _�__.. Number of bedrooms. Number of aths _.J.__ Lot size _____/_�_(� �_D-CG <br /> ----- <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 3' (_ ft, , <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay p Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes p No �lew Construction: Yes g !o ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tan : Distance from nearest well___�G-1....Distance from foundpfion___-_ -�_�______.Material___ ----------------------- <br /> ��_t_ ' <br /> -------------- <br /> ------- <br /> Size-- �r Liquid depth_-- �` :� --- Capacity ' <br /> p p well ------_-------_Distance from foundation_..___�d_rDistance to nearest lot line.___ <br /> . o compartments men s__. <br /> Qis osa! Field: Qisrance from nearest ,- <br /> Number of lines------------+�.�___ ____ <br /> -----Length of each line _y-_(i_�----_----.Width of trench---------- <br /> ------------ <br /> Type of of filter material- ,---Depth of filter material---------t?.......Total length______- J__ ___________________ <br /> ____ <br /> Seepage Pit: Distance to nearest well Distance from foundation___-_______._--_--_.Distance to nearest lot line --- <br /> ❑ Number of Pits-----------------...__Lining material----------------------.Size: Diameter-----------------------Depth-_------------------------ ----- <br /> ---------------- --- {�V <br /> Cesspool: Distance from nearest well_________________Distance from foundation-----------------__.Lining material _ __ <br /> El -Size: Diameter-----------------------------------_-Depth----- --------------------------------------------Liquid Capacity <br /> q ---------------------- -----gals. <br /> Privy: Distance from nearest well______________ ------------------------------. --Distance from nearest building <br /> ❑ Distance to nearest lot line--------- <br /> Remodeling and/or repairing (describe):----------------------------- <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 reTla4ons of the San Joaquin Local Health District. <br /> [Signe 1 <br /> - �4­ �------- <br /> (Owner and/or Contractor) <br /> By:-------------- ., _... <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 <br /> REVIEWED BY-------- � - '�----------------------- <br /> -----.- ----- ----------- ----- - ---- DATE <br /> ---- ------------------ ----- <br /> BUIL <br /> DING PI=RMIT ISSUED---------------------------------- ----- <br /> -------- ----- ---------------- DATE--- --------------------- <br /> ------------------------------A terations and/or recce)rrnendations:---_--.-------- - - <br /> ------------------------------------- <br /> , <br /> FINAL INSPECTION BY----------------- --------- <br /> ---- ------------ Date_ � <br /> ------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street <br /> 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California <br /> Tracy, California <br /> E5-9-2M 8-51 Revised W-2)00 <br />