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APPLICATION FOR R SANITATION PERMIT Permit No. .......... ...... <br /> (Complete in Duplicate) _ <br /> Date Issued <br /> Application is"here6y made to the San Joaquin Local Health District fora ermit t <br /> This application is made in compliance with County Ordinance No. 549. p o construct and install the work herein described. <br /> JOB ADDRESS AND LOCATION...............222f---E..::Ai1it ....---------------"=---'--=-.:.--------- <br /> Owner's Name------------ !Qf.11A. ------------------------------------------------- ------ Phone-----4,'Q°8'9j6-------------- <br /> Address.................................SELM <br /> Contractor's Name.. I)elt3, -T-no.,----------------------------------------- --------------------------------------- Phone------.1-—_9.5_ <br /> ---------------- <br /> 5. <br /> Installation will serve: Residence [1k Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ -'Other E]Number of living units: -__._-- Number of bedrooms --- -, Number of baths ---1. Lot size ---70X -5-0-__.- _.__._.._.._________ <br /> - <br /> Water Supply: Public system [2 Community system ❑ Private ❑ Depth to Water Table -40 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 [N New Construction: Yes ❑ No []C <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_________________Distance from foundation--------------------Material <br /> EXIS"NG No. of compartments--------------------------Size------.------------------------Liquid depth---------------------------- <br /> Disposal <br /> ----------- - ----------Disposal Field: Distance from nearest well_.----.-------._Distance from foundation..__-..-_--__---.Distance to nearest lot line_.__ <br /> EXISTING Number of lines-----------------------------------Length of each line____..____-- -_.__ --__._.Width of trench------------------- <br /> ` <br /> Type of filter material__ --_---__. ___ _-Depth of filter material-----_------------------Total length__________________________________________ <br /> Seepage Pit: Distance to nearest well------no-----------Distance from foundation.___.-9.1....._....Distance to nearest lot line----,r........... <br /> [A Number of pits__].----------------Lining material-- r -C,'x____.Size: Diameter-__. !--------------Depth_-_______� _t_____________• <br /> Cesspool: Distance from nearest well------------ <br /> - Distance from foundation--------------------Lining material_-.--_.__-----___--___:__.. <br /> --------- <br /> .l <br /> El 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):-----------ver t------------------------------------------------------------------------- <br /> ........................................................................................ <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 regulations of the San Joaquin Local Health District. <br /> (Signed) 2I _,__-I `•----------- ----- ---------------------------------------.(Owner and/or Contractor) <br /> BY:----_-----------------------..................Peri- ---Wax-than------.- ,_oma- ---------------------Title ,r-------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FO E TMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------------------- -- -- -- ------ DATE--------- �. <br /> IEWEDBY --------------------------------------------- ---------------- DATE <br /> ----------------------------------------- <br /> UILDINGPERMIT ISSUED...................................................................................................... DATE - <br /> Alterations and/or recommendations__________________________________ <br /> ----------------­----------------------------- ........................................................... <br /> ---------------------------------------------------......•--------.------------------------------------------------------------- <br /> ---------------------- ------------------------------ --------------------------------------------------------- <br /> FINAL INSPECTION BY-------------- i '✓!.% ll ----- Date..---- -----k"7_. .3 .3 <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 />