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� Y <br /> APPLICATION FORS'SANITATION PERMIT Permit No. �.. .------, <br /> (Complefe in Duplicate] <br /> Date Issued - --s- <br /> Applicafion 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 Ordinan 549. <br /> ADDRESS <br /> Y • f . <br /> JOB ; AND LOCATION <br /> � <br /> ..------- 0 ------ -&)A 1 <br /> ---- --- ------- ----- <br /> Owner's Nam +-� _ $ ----- - --------------------- <br /> Owner's <br /> -T---------•---- <br /> •----- ---------- ---- - --- r <br /> r r _. = - ----- - I! Phone �� /sem . 4 <br /> -r <br /> Address_ 4 F <br /> -- --- <br /> --------- ---- <br /> Contractor's 'Name = 7---- ----------r------------------------------------------------ * o <br /> Installation will serve: Residence Apar ment Hause ommercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> 'Number <br /> V <br /> Number of,,living units: _ ----- Number of bedro, .. umber of baths .--/--- Lot size <br /> Water Supply:•,'Publ*c�system ❑ Community system- rivate Depth to Water 'able <br /> Character of;soil to a depth of 3 feet. Sand 0 - Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob�` Hardpan ❑ <br /> Previous Application Made: Yes I] No Z New Construction: Yes No ❑ <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 weft_ `��---___1?istance from foundation--- ------------_.Material_----_- <br /> p No. of compartments---- � ------Size--------------------------------Liquid depth--------------------------Capacity.---:--- <br /> ---1 ' <br /> Dis osal Field: Distance from nearest well__- �_'_ Distance from foundation--,/D___------.Distance to_nearest lot line__ ---__--- <br /> Numbe�of lines---- ---------- Length of each line----.____ - <br /> 1 _ 9 �0-----------_Width of trench-- <br /> Type of filter material - --.-' Depth of filter material--_.-- - ' <br /> = p /���- -- - -Total' length -- - - ---------- -- -- <br /> Seepa ePit:' Distance fin nearest;well--__ ep -------Distance f om f nda ion_- O__..._-Dis#ante to near - ina__--- <br /> Number of pits..--_/-------------Lining materia- JSize: Diameter--__-�.----_- 1 <br /> x t <br /> Dep#h-._ a f <br /> Cesspool: Distance from.neares# well-------------- Distance from foundation---!---------------Lining material__---_-.--------.___--------___------. <br /> ❑ Size: Diameter------------------------------------ Depth--------------------------------------:---------------Liquid Capacity_=-----•-------------.---..-gals. <br /> Privy-:';"- Distance ,rom neae <br /> rest wll--:. --------------- <br /> 'Distancefro�m Barest buildin <br /> Distance to nearest lot line_- <br /> ------------------- T ----- ,.:.---------- <br /> k, w <br /> Remodeling and/or repairing (describe)----------- ------------ --------------- <br /> ----------------- ----- . -• r <br /> t <br /> i ..4 <br /> :. = ----------- -------------•----------------------------------- <br /> ___._---_•-_--••---------------•-•---_•----------------------------'•-----------------------------------------••-•------------•--------------••-----------__-•-----.__--_.-_--------_-•_-_-- <br /> * --•-----------'-------------•------ <br /> I hereby certify-fhat I have prepared this application and that the work will be done in accordance with San Joaquin Coun <br /> ordinances, State la and ou�ln( egulation af^f a San Joaquin Local Health District. <br /> (Signed)------------- ---- I + <br /> ----------------- ------- ----------- <br /> e __(Owner and/or Contractor) <br /> 13y:. p '--. --. ------ _ � -------------7 ...(Title) �------r -- ---------------- <br /> (Plot plan, showing size. of lot, !�r'ation of system in relation to wells, buildings, etc., can be p1ged on reverse side <br /> --------------------- <br /> f FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------------------------------- r------- ---------- DATE-------- '� \ <br /> .>�P <br /> REVIEWED BY= -- ---------- ---------------------- ••------- DATE---------------- <br /> BUILDING PERMIT ISSUED-_..---•----------------------------------=-----:----------••------------- ----------------------- DATE---------------, ' <br /> Alterations and/or.recommendations:....°---:-------------------------- <br /> ----------------­--------- <br /> ---------------------••---•----------•------ ---------• ----•-----------_t = - ! <br /> ----------------------------- -------------------------.-----------------------------------..-----•--------•----------t := , <br /> ----------4---------------- j , <br /> ---------•------------- <br /> 4 B <br /> + o t <br /> -------- -----°------ ---------------------- ---------- ------------------ ----------------I-•----- -- <br /> ` s <br /> FINAL INSPECTION'BY: -------- --- Date---- -------------------- !-..... _ <br /> ' E/� /-5r u e ) 1'•v Y7 <br /> . <br /> SAN O 'QUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street- 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />