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n <br /> !f/..-�.- <br /> [ <br /> i� Complete ompAPPLICATION FOR SANITATION PERMIT.. Permit No - <br /> Clin Duplicated -_ <br /> h� Date Issued --- .]--------- <br /> I - • W <br /> Applic&ion is hereby made to the San Joaquin Local Health District for a permit to�ptrust and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. 7g km : C75-,r — pC .-pS <br /> RADDRE55-AND.LOC TION--- ----------------------------- h -----`-=�------- <br /> R � _ .. one <br /> Owners Name2....-, --�� -- - - - ---------- ----------- <br /> ------------ - --------- <br /> I� Address------ -- .. �� --- �C_ <br /> •i� <br /> Contractor's Name_-•-----_------------ -- - . -. -------------- - -- ------------------------------------------------- ------... Phone.3-------•-•------------- <br /> Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ <br /> i Number of living units:: ___ Number of bedrooms __-° Number of baths ___l__ Lot sizes`�,lY_ _ 3a -------------------- <br /> Water <br /> Water Supply- Public systemX Community'system ❑ Private E] Depth to Water Table :9 ft: <br /> Character of soil to a depth of 3�feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeg Hardpan ❑ <br />�-� -Previous Application:-Made:-Yes-❑m NotATIONS::New.Construction: Yes ,sNo.❑TYPE OF INSTALLATION AND'SPECIFi <br /> -(No septic tank or cesspool permitted if public sewer is available within'200 feet: � I' r\} <br /> _ _ /.... ,4 - . <br /> Septic Tank: Dis ante from nearest well Distance from foundation---/4- Material_'__ -------- W <br /> No of compartments------ S�-_- - 4-__:...Liquid depth__/ _-____ -_Capac�tY_. _5--�_ <br /> Disposal Field: Distance from nearest well .Distance from foundation___ '_"_.._Distance to nearest lot line_-____ <br /> Numnber of lines-------- ' <br /> .f --:,_:-- __--Length of each line........ -------------------Width of trench_-_-- __-- -----------------_--•-- <br /> T e of filter material-,�t___ . _ - -.De Depth of filter materiaL, _-/V_..______TotaE length______--_ <br /> Yp p ---------------------- <br /> Seepage Pit: Distance to nearest well_ -�----Distance from founda#ion___-2_ ''.___.Distance to nearest 10# iine__ �------- <br /> Number of pits-------1------------Lining materialO� Size: Diameter-__ +3 /_______Depth_-��-- - S""------ <br /> Cesspool: <br /> --.Cesspool: Distance from nearest well-----------------Distance from foundation----------------- <br /> . _. ❑- - - = , material__.__._______--__________________ <br /> Size:_Diaroefe --------- -------- - -- .---- _ --x---- - -- -----------r-- <br /> .. <br /> Li uic1 Capacity --gals. <br /> 1 r_ ,f <br /> Privy: Distance from rom ,nearest,well--------------------------------__""'_'='-=Distance from nearest building-------------------------.___---_..____._. <br /> i ❑ -'Distance to nearest lot line--------------------------------- ------------------------------------------------------------------------------------ --- -------- <br /> Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------•--------._.._......._...-------•------------------------ <br /> -------------------------------------------------------'--------------------------- -----------------------------•-•--------------------------------------------- ----------------------------.------------------------------ <br /> •--•----------•------------------------------------------ <br /> r <br /> hereby certify that I have preparegd this application and that h w will --- e in -accordance -- <br /> - --- -- -- ----- -- ------------------------------------------------------------------- - <br /> the work will be done in accordance with SanJoac}uin County <br /> ordinances, State laws, and rules-and regulations of the San Joaquin Local Health District.rD <br /> ; <br /> �,..�.......�.. ,...<... �.,..�., - - F <br /> .......... =_ and/or.Con+ractorj,.� rt------------------ <br /> __. . ._ : <br /> 1 By:-----------------------------------� �------. [Title <br /> (Piot plan, showing size of lot, location of system in reletio o wells, buildings, etc., can be placed on reverse side). <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------- -- - ---- -- DATE______ <br /> -- ---------------- <br /> REVIEWED BY --- ------------------ y� DATE <br /> -------------------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-----------------------� -.1:------------------------------------------------------------- DATE------------- ------------- ----- ------------ <br /> Alterationsand/or recommendations-----------------------------------------------------------------••-------------------------------•-------------------- - :. <br /> i ----------------------------------------------------•------------------------------------------------------------------------------------------•--------------------------------•------------------------------------------ <br /> i ----------------------------------------------------------------- ------------------------------------------------•---------------•--------------•---•-••-------. ------- ............................------------ <br /> ' -- <br /> ----------------- -------------------=-------- ----- ------------------- ------ ----------- <br /> -----------------------------------FINAL INSPECTI ----- ----- ----------------------------------------- ----- _ Date ------- <br /> SAN <br /> 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 />