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APPLICATION FOR SANITATION PERMIT Permit No. . .1--. ..Y <br /> (Complete in Duplicate) <br /> Date Issued ....._ � _, .� <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 /> JOB ADDRESS AND LOCATION-------- ----- . .............--------------------- <br /> 4 <br /> 1 : !!,i <br /> Owner's Name �Ql?-�L� �-s-kl- ----------------------------------- Phone. -a <br /> _ . -- ` <br /> Address ......••. --- -------------•-------........... <br /> Contractor's Name--------------------------------- � .r.. --------------------------------------------------- Phone........- <br /> Installation will serve: Residence ;ff Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __.,l__ Number of bedrooms A-- Number of baths Lot size ___. /_L_L2__--------------- <br /> Water Supply: Public systemCommunity system ❑ Private ❑ Depth to Water Table --- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan ❑ <br /> Previous Application Made: Yes ❑ No J4 New Construction: Yes ❑ No ❑ Q4,f1,,, <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: V <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> tic Ta k: Distance from nearest well_________________Distance from foundation--------------------Material---_.__-___----____---__-__-.---_-_--__-.--__--_ <br /> tic Ta <br /> No. of compartments ---Size------------------------ --Li Liquid de th---------------- ----Ca Capacity�-- 7 P q p. P Y <br /> Disposal Field: Distance from nearest well.# -----Distance from foundationlZ-_LZ ---__---.Distance to nearest lot line_.__.? <br /> Number of lines-----I___•--.____J--_.____-_---Length of each line___4__`_O_._--------------Width of trench._Ate:"-__----____._.-_-_ <br /> Type of filter material__-_ .--_Depth of filter material----------/_if''_.-Total length.........4`Q____________ _________� <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 /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material------------------------------.__--__. <br /> ❑ Size: Diameter--------------------------------------Depth--------------------------------- ------------------Liquid Capacity---------------------------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 cerFrFyfhat I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Sta4,laws and rules aegulations of the San Joaquin Local Health District. <br /> (Signed) n'`--'11, <br /> --------- Contractor) <br /> By:..................-----------------------------------------------6nr <br /> --- '" ,�'- ---�------ -------------(Title)--- Q <br /> (Plot plan, showing size of lot, location of system into wells, 6uildi s, etc., can be pl cad on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> 11 <br /> APPLICATION ACCEPTED BYKt---------- --------------------------------------- DATE <br /> ----------------------------------------- -------------------------- <br /> REVIEWED BY � -------------------------------------- ------------------- DATE <br /> BUILDING PERMIT ISSUED-------------. ----------------------------------------------------------------------------------- DATE------- <br /> Alterationsand/or recommendations-------- ----------------------------------------------------------------------------------------------------------------------- ------------------------------ <br /> -------•------------------------------------------------ ------------ ---------- .................................................._.-......................=.................................. <br /> ---------- .------ <br /> ------------------------------- -------------------------•--------------- ---------_----------- -------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- <br /> ---------------------------------------- ----- - -- ­-- ----------------------------------------- ----------------------------------------------- ------- - ------- - - -- ---------------------------------- ....__ <br /> FINAL INSPECTION $Y:. °'__ ',� AZ". �, ;_______..- Date..... - fi <br /> d - At 11•� <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 />