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APPLICATION POR SANITATION PERMIT Permit No. __caw_ <br /> (Complete in Duplicate) 3 <br /> /L Date Issued ----_ 3�------------------ <br /> Applicaa-ion 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 <br /> • Oinance S49. <br /> JOB ADDRESS AND LATI --- <br /> - <br /> c <br /> +----------------------• -------- -•----------------------------•---- <br /> .._-_ . ------------------------------------- ------------- <br /> Phone.Owner's Name----------- �., _ <br /> Address._--_----------------- -•----•---------------------------•--- <br /> Contractor's Name...--�---•--•------------------------ ---------------•-------=--------------------------------------------------------------- ------ Phone----------------------------------- } <br /> 1 <br /> Installation will serve: kResidence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---I--- Number of bedrooms rl. Number of baths _ _ __ Lot size ---------------------- <br /> Water <br /> -_____________Water Supply: Public isystem 5?000C� ommunity system ❑ Private ❑ Depth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet:, Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Lpam ❑ Clay ❑ Adobe Hardpan 0 <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: , a <br /> (No septic tank'or cesspool permitted'if public'sevrer islvailable_within 200 feet.) <br /> $ep ' Ta i Distance from nearest well-____-__.____'D.is'tance from foundation___-.__.__________.Material---------------------------------------------- <br /> _. I <br />' No. of compartments-------------------' '"Size:- "== -------Liquid de.th--------------------------Capacity-----------•----- <br /> -- <br /> � <br /> Disposal Feldl Distance from nearest well.. istance from foundation Distance.Distance to nearest lot Gnej_____J�____-_--- <br /> Number of lines--------------- r---s_--tLength of each line----1Z--- -- ---.Width of trench---_- --_�,. --------.---------- <br /> Type of filter material-_.__ __ ____ _ epth of filter material=___._�_?__.________Total length---._--. �___________________________ <br /> ou .ti ... <br /> Distance to nearest'well_._.______----------- <br /> _______Distance from foundation....................Dis#ante to nearest lot line______________. <br /> ❑ p- g <br />} Number of its------- --'.-----------Linin material--_-- -- ' >--_Size: Diameter------------------------Depth:----.-------------------------• <br /> A j <br /> Cesspool- Distance from nearest well________________Distance from foun6fion- _,-.- Lining material-----------.__----_-__.----__________ <br /> Size: Diameter--------k-----=-----------------------De th----------:=h==` ------------------------------Li Liquid Capacity , <br /> ❑ � _ � p ._ g ---------------------------gals. <br /> Privy: Distance from nearest well-__._�t_______________.______:____:` ;_'Distance from nearest building__________________________________________ <br /> ❑ Distance to'nearest#lot•line-° _ .`...."!_. _ r.� <br /> --- -------------------------•-------------- <br /> Remodeling ono'/or repairing (describe]:___.____.________._____. ................................1 <br /> s_ r, -- <br /> --------------------------------------=------------•---•------------------------------------------------------ =-------`------------------------------•------------ -•-------------------•-----------------------•------- <br /> ------------------•----- -------------------------------------------;W---•----------------•-----------•-----•----------------------•---------------------•----•-----------------------=--------------------------------------- <br /> f �' -.r <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. F <br /> (Signed --------------------------------------------------'------------------ Owner and/or Contractor <br /> 1 <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 /> ' 9 <br /> I FOR DEPARTMENT 115E ONLY <br /> APPLICATION ACCEPTED BY---- - ------------------------------------------------------------ <br /> DATf 2--- =---------- <br /> REVIEWED BY------------------------------------------ ------------------------------------------------ DATE----- -. -- <br /> .3_ ---------- <br /> BUILDING PERMIT ISSUED---------- -----=--------------------------------------------------------=------------------------ DATE----- -------------- .4 - <br /> Alterations.and/or recommendations:----i------------------------------------------------ -------------------------------­---------- <br /> ----------------------------------------------------------------- ---------------------------------------------------------------------------------- -----------------------•------- <br /> ------------------------------------- -------•-------------- ---------------------------------------------------------------------------------------------------------------------------- ---------------------------- ------ <br /> -------------------------------------------- ------------------- ------- -- -------- ---- <br /> ------------------------------------ <br /> FINAL INSPECTION BY:-----------== -- „"°=---------'- - Date--------_---`_�_•___`9=__ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 Soufh American Street 300 West Oak Street x 932 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5-9-2M Revised W-2100 <br />