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( pu-� APPLICATION FOR SANITATION PERMIT Permit No. <br /> \ (Complete in Duplicate) /� <br /> V, • — 1 I ____________Date Issued _ -3_ -,1-3 <br /> A plication 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 OCATION---�-"?_-- --------••-- - i•---. - ---------*------------------------------------------------------- <br /> 4 Name- -- - -- -----�!---------- Phone <br /> Address ........... ----- 4 <br /> n } -------------- -------------------------------------------------------------------------- <br /> 71.Contractor's Name---_ -.�.__.. _ _. _ .. ,�G --- ----ph71.l 'LPl Phone '0_ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: .-.... Number of bedrooms -_Z. Number of baths -1.... Lot size ----- ------------------- <br /> Water Supply: Public system A—Community system ❑ Private ❑ Depth to Water Table _Vj ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe*00HOardpan ❑ (1 <br /> Previous Application Made: Yes ❑ No '""`New Construction: Yes ❑ No 40' <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 /> No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal Fiel : Distance from nearest well-----------------Distance from foundation-•.__---_---_--__---Distance to nearest lot line----------------- <br /> Number of lines-----------------------------------Length of each line------------------------------Width of trench----_-.-__--_--_.-.___-_---_____... <br /> Type of filter material_________________________Depth of filter material--------------.--------Total length.......................................... <br /> Seepage Pit: Distance to nearest wellDistance from foundation____2-40.. -.Distance to nearest lot line_-. 2._...._ <br /> �...►" Number of pits------- Lining material_ �. - Size: Diameter__-.94- �____.Depth___..-Q_�_________________ <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-----------------.--___-_--._-.__-._ <br /> ❑ Size: Diameter--------------------------------------Depth-----------------•----------------------------------Liquid Capacity------------------------_--gals. <br /> Priv Distance from nearest well-------------------------------------------------Distance from nearest building <br /> ❑ Distance to nearest lot line---------------------------------------------------------------------------------•--------------•---•---------------------------------------- <br /> Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------------•------------------•-----•-------------.._.........------ <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 San41 ,004%.4 <br /> yJoageuin Local Health District. <br /> (Signed)_._z ' t ___ot�A�- �+�-,.- '�- 04"Y 4---------- --------------------------------------(Qwrlor'end•Jw Contractor) <br /> BY: (Title) �1k.*r9ot -'----- -------------- <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 /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- <br /> Alterations and/or recommendations:-------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------ <br /> -------------------------- <br /> -------------------------------------------------------- --------------------------------------------------------------------------------------------- ------------­------------------------------------------------------ <br /> FINAL INSPECTION BY:.--- --"'---...`------------=---------------------------- Date--------------------/--�------------------------------------------------- <br /> SAN <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 to-52 Revised W-2100 <br />