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APPLICATION FOR SANITATION PERMIT. - Permit ---------------- <br /> [Complete in Duplicate) . Date lssuecp/-/V/ <br /> T_ <br /> a+ion is hereby made to the SanJoaquin Local Health District for a pe mit to constru n ins 11 the gcorlk herein dKcribed, <br /> T�is_pClcipplication is made in compliance with Cou y Ordinance No. 549. <br /> C/ <br /> JOB ADDRESS AND LQCATI0 ----- ---- - ------------ - <br /> Owne�r's Name-- ---- -- -------­------------------ - -------------------------------------------- Phone--- <br /> `Address- -- ------- <br /> --- ----—----- ------------------------- ---------------------------------------------------------------------­---- ------- .......... <br /> ! <br /> 'A Contractor's Name -------------------------------- ---- -- - -- --- -- --- ------------------ -------------------------------------------------------- Phone..------ - - <br /> Installation will serve: Residence Apartment House'[-] Commercial [] Trailer C6urt E] Motel E] Other E] <br /> Number of living units: -'Number of bedrooms 'Number of baths sZ. Lot size -—------------------------------- <br /> Water Supply. Public fo'Water'table - <br /> syste Community syifem 0 'Private E] Depth ft.. <br /> MX <br /> Sand [] Gravel ❑ Sandy Loam ❑ Clay Loa�3K Clay E] Adobe El Hardpan ❑ <br /> Character.of.soil to a 'depth of 3 feet: <br /> _Z <br /> :Previous Application Made: Yes 0 N6- Now Construction No El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS:. <br /> (No septic-tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic To Dsf6nce from-nearest well------------------`Distance from foundation_______________ <br /> ---..Material_:---- ---------------------------------------- <br /> ep ic <br /> No "of corn' -------Liquid clep�h-------------------------CapacitY-•---------•------------ <br /> Z", pa rtmen fs------------------------:Size....... --------- <br /> lmsno�- Distance from nearest well..�__ foundation---------------------Distance to nearest lot line____-_---__-._... <br /> Disposal Fie e -------------Distance from <br /> Number of lines--------------------------------------1ength of each line------------------------------Width of french._------------------------------- <br /> * Type 0 <br /> , f filter material........................Depth of filter material-----------------------Total length------------------------------------------ <br /> Seepage Distance to nearest wel --------TistanceJroT ation-. to nearest 10717 T_i5l------ <br /> Nu Inber of pits------/-----------Linin- <br /> i n i n g m'-a f e r Ae Size- ------ -1 --------------- <br /> Lining <br /> Poo: _2n: <br /> Disfanco'fi,om'666r�-e-sf-iiv--e;ll=:�7!�Disfance from foundation-------------------- material------ -----------------------------n�: <br /> C --------------gals. <br /> El Size: Diameter_'=---------------- -------------____-Depth----------------------------- ------ ------ -- ---Liquid Capacity----------------- <br /> I % , I il 4 �w !L <br /> Privy:i D�S'fance'from nearest well-------------- --------­--------------------Distance from nearest.building--;----------------------------------------- <br /> 4- <br /> El •-Distance to nearest lot line---------------- - -- ------- ------------- ------ -- ---- - ------------------------------------------------------- <br /> I <br /> ribe):-- ----- ...... <br /> Remodeling and/or repairing (d <br /> -------------------------------------- -------------- ----------------------------------- -----------x-------------------------------------------- ------------------------ ------ ---------- <br /> 4. <br /> ? _1�1 N4.� _11� <br /> -------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------:---------------------------------------------- <br /> ------------------------------------ - ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - <br /> .IV <br /> ll'�hereby certify-that I have pre a�ed'fkis'�if-ipli6-afi�--��a—ndxfirai*ft�e=ork will be done in accordance with San Joaquin Coun <br /> P, <br /> ordinances, State-laws and rules and reg lations of fhe'San Joaquin LocaI Health District. <br /> if <br /> (Signed)......... --- - ---:A---- -- -----------------------------------------------`-------------------------`----------------------{Owner and/or Contractr) <br /> By:----------------- -�J <br /> -----------------------z-------------------------------------------- <br /> ------------- ------------- <br /> (Plot plan, showing size0 lot, location of system in relation to wells, buildings, etc., can be placed on reverse siql#). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------- ------ -I--�------------------i --------- --b- - DATE----------------- <br /> REVIEWED BY- -S---- ---------------------- ----- DATE. ..... ------------------------ <br /> ------------ <br /> BUILDING PERMIT ISSUED i - -J--------------------------- ---------------------------------- ­ DATE -------------------------------------------- <br /> end�fli' 's'l-:,... ------ <br /> AIteri46_n­siR'd/8i_4_CA/r;6 1-4 dn --- ---------------:�Z------_-------------------- -- -------------------------- - ---- ---------- <br /> 4--� -A41, ------ ------- . ......... <br /> ------------------------- --------------r---- : I <br /> ----------7--�`T­- <br /> ----- ---------- ..............11.......... ....... .... <br /> --------- --- ----------7------ ----------- ---- <br /> ---------- <br /> -- -------------- - -- - -----------* <br /> --- - ------ <br /> ---------------- <br /> FINAL INSPECTION B - - --------- ----------- -------- ---- 1/Dafe_r_a�--------------- <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 />