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,!, ,(� APPLICATiON PC SANITATION PERMIT Permit No. ......... <br /> (Complete in Duplicate) Date Issued <br /> I <br /> Ap liciation is hereby made"to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> ('-�-,Tapplicafion is made in compliance with County Ordi. e No. 549 ) <br /> JOB ADDRESS A LO TI - -------- --------- -- - - ----- - ----- <br /> - ------------ <br /> O�vner's Nat <br /> JA�d1r-------- -- -------------------- ---------------------------------------------- ------------------------------------------------------------ <br /> re <br /> C'Onf ractor's Name----., ------ ........... <br /> ----------------------------- ----- Phone------- <br /> lristallafionYwill serve: ResidenceX Apartment House E] Commercial E] Trailer Court [] Motel L] Other El <br /> ---------------------- <br /> Number of living units: __/---- Number of bedrooms ,.Z Number of baths Lot size <br /> Water Supply; Public system El Community system El Priva te/k Depth to Water Table--_ ft. <br /> .. I �j <br /> Characfer.6f soil to aldepth of 3 fee+: Sand [] Gravel E] Sandy Loam [-] Clay Loam,` Clay E] Adobe E]* Hardpan Ej <br /> F're- cation Made;:� Yes El No/K/K New Construction: Ye No E] <br /> 4 j <br /> TYPE OF,INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank,or cesspool permitted if public sewer is available within 200 fee+.) <br /> A 1: <br /> pti< Ta W Distance from nearest well_________________Distance from foundation_.._-_-_-------__-_.Material-__-________.__..__-__________._.-_________-- <br /> ' <br /> ----Material------------------------------------------------- <br /> c <br /> No. of compartments----- ------- ----------Size------------------------- ------Liquid depth------------------------._Capacity..-------------------- <br /> PT'c 'a <br /> ispo al Fil Distance from nearest well----- -----------Distance from foundation--------------------Disfance to nearest lot line_________________ <br /> is os <br /> N�mbeor <br /> r. I lines-----------------------------------Length of each line-----------------------------.Width of trench.---------------------------------- <br /> Ty.pe of filter material------------------------Depth of filter material-----------------------Total length__________________.___..-_-_________'_-_. <br /> j i. <br /> ----- Distance toj:nearest lot line________ <br /> Seepage if: Distance to nearest well-A ----Distance from fundation---la-- <br /> V.e' <br /> Number of pits-----I--------------Lining material . . ......Size: Diameter- Depth----tp4W7------------------- <br /> 0 Distance from. nearest well-----------------Distance from foundation--------------------Lining material-_.-__.-__-_---_________._____._-___. <br /> F-I Size: Diameter--------------------------------------Depth-------------------------------------------- ---Liquid Capacity-------- y_.-a: ------gals. <br /> Ir �rrivy: I Dis'fanc'e from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- <br /> FDistance to nearest lot line------ --------- ------------------------ ------------------------ ------ ­----------------------------------------------------- <br /> -P <br /> o r r ------ --------------------------------------------------------------------- <br /> 'I I ne------------- - -------- -----------------•----- ------------ ----------- ----- <br /> I - <br /> R6ry�6clelirlg and/ repairing --------------- ----- ­-- ---- <br /> -- --------------- - ---- -----------------------------------------•----------------.-.---••------- .......... - - ----- -------- ------------ ------------- ----------- <br /> ------------------------------------------ ---------------- -------- ------- <br /> ----------------------------------------------------------------------------------------I.......I-------------- -------------------------------------- ---------------------------------------------------------- <br /> -------------------------------------------------------­----------------------------------------------------------------- ----------------------------------------------------------------------- ------------------------- <br /> 1 here6y'certify that I have prepared this application jlthat the work will be done-in accordance with San Joaquin County <br /> 'ordinances, S laws, an h rules a r tions 0 SJoaquin cat Health District. <br /> -- ---- ----- -- -------------r_/----------------------------- ---- '(Ow ea /or Contractor) <br /> 3(Signed)------ <br /> By:-------------------- .. .... - - ---- ------ - --- ----- ---------------------------------------(Title -- ---- -- ---- ---- ---- ------- <br /> (Plot s e)'0 <br /> -(Plot plan.'Showing siz .. o+, 10 io system relation to wells, buildings, etc., can be place on r er <br /> FOR DEPARTMENT USE ONLY <br /> 'APPL.ICATI'ON ACCEPTED BY-- ----_v------------------------------------------- -------------=-------------------------- <br /> ' BY-------•---=-------------------i DATE - - <br /> W1 ------- ----------------- DATE-- - <br /> ----- ---------------------------------------------------- -- <br /> - <br /> REVIEWED - <br /> BUILDING PERMIT ISSUED..........------------ ----------------------------------- ------- --- <br /> DATE__ <br /> -- ---------------------------------------------- <br /> Alterations-and/or-recommendafions:-- - - -- ----- -- ---------------- - -... -.. ----------------------------------------- <br /> - <br /> ----------I--------------- ----------------------------------------- <br /> - <br /> ------------------ --------- .... <br /> ----------------------------------------------------------------------- --- ------------__ --------------------- --------------- ------------------------------------------------------ <br /> -------------------- ------------------------------------------------------------ --------------I-------------------- <br /> --------------------------------------------- ------------------------------------------------------ --- -------------------------------------------------------------------------------------------------------------------- <br /> ------------------------ ---------------------------------------------- ----- ------------_-------------------------- - --- ---------------------------------------------------------------------------------------------- <br /> Date-------j <br /> . -/----4_---I----------------------------------------------------- <br /> ANAL INSPECTION ---------------------- <br /> SAWJOAQUIN 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 /> E5-9-2M 10-52 Revised W-2100 <br />