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1 <br /> APPLICATION FOR SANITATION PERMIT Permit No. ------- <br /> (Complete <br /> .---.- <br /> x (Complete in Duplicate) <br /> Date Issued <br /> Applica�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 Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION_ �" d ° ! -- ---- .... <br /> ---------------------•------------ <br /> Owner's Name = '---•--• ----•----- Phone__ { <br /> o-•••-•----�--•--•----3-1a- ------------------------------------------------------------------ <br /> Address.---.-.- . _ 1 d � <br /> Contractor's Name-------p' = ' [.�{1----------- �� -------------------------_------------ ------------ ..... Phone.)V _--G ..'.960_7 <br /> Installation will serve: Residence Apartment House ❑. Commercial .❑ Trailer Court ❑ Motel ❑ Other ❑ # <br /> Number of living units: ___/___ Number of bedrooms __A__ Nymber of baths __f..._ Lot size __'._ -P9------x_-1,40 <br /> ------------------ <br /> Water Supply: Public system ❑• Community system R._ Private'_❑ Depth to Wafer 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 EEr New Construction: Yes M. No ❑ 8 � <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: rf�e fl n nearest well-----------------Distance from foundafion--------------------Material------------------------------------------------- <br /> El No. of com artments--------------------------Size--__:-4-------.----_--••-------Liquid de th-------_-------------_---_Capacify-'- <br /> Disposal Fie d Distance from nearest well---- ---------Distance from foundation__..-----------------Distance to nearest lot line----------------- <br /> gNumber of..lines-----------------------------------Length of each-line---- ---._----- --------`'-Width of trench----------------------------------- <br /> QType of filter material------------------- ---De�th of filter material------------------------Total length------------------------------------------ <br /> F <br /> Seepage Pit: Distance to nearest well________`�5-_______ is e rf m foun a on__:_�_ __0_ ,,_1a_r5c to nearest linej______ ___.__ <br /> Number of faits--------_�------_-----Lining mat riaL_�-�--Q!±N-«ize: iamet �.., --------Depth ----�-�---.._�- <br /> Cesspool:. Distance from nearest well________________ tante fro ation__------------------Loring 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 /> 4 <br /> Remodeling and/or repairing (describe):-----------------------------------7-------------------------------------- ------------------------------------- <br /> --------------------------------- - ­­-------------------------------------------------------------------------------------------------- ---------------------------------------- -------------------•------------••---------------------------• <br /> -- <br /> i <br /> --- <br /> ------------------------------ ---------- •-------------------••---------...-.. ----------•-------------------------------------------------------------------------------••---------------------------------------- <br /> hereby certify that I have prepared this application and That the work will be done in accordance with San Joaquin County <br /> ordinances, State la5end rules and regulations of the San Joaquin Local Health District. <br /> (Signed)------------- --- - L � C----------------- ------------------------------------------------------------------------Owner and/ or ContracA . <br /> #or) <br /> BY .... - _ _. ••-----•.(Title)-------- '1 <br /> �* (Piot 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 /> - r <br /> APPLICATION ACCEPTEp :---- --- DATE------- - <br /> ----- ------- -------- -- --- <br /> ----------------------------------------------- <br /> REVIEWEDBY--------------------------------------`-------- •------•--------------------- DATE------- ------ �----------••---•----------•-------- i <br /> 7 <br /> BUILDING PERMIT ISSUED------------------------------- <br /> ------------------------------------------ ......_. DATE.-------------- i <br /> -----•---- <br /> Alterations and/or recommendationsc__._._ <br /> -- -------------------- <br /> ------------ <br /> -------------------------------•---------------------------------------------------------- ��--- ----.............-----•--• ---------------•--------------••-•------- <br /> ----------------------- <br /> -------------------------------•--•---- ----------------------- -------- -----•--------------------------------------------------•-••---•----•--•--------------------------------....._ <br /> % <br /> FINAL INSPECTION BY:_.: -- = r -------------------•----- Date------. - --------------------------------. <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 ; Revised W-2100 <br />