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APPLICATION FOR SANITATION PERMIT Permit No. ._�_4_`3 ._ <br /> (Complete in Duplicate) Date Issued .__'�_`�_�_�S Y <br /> Application 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 rdinance No. 549, <br /> f ,, <br /> JOB ADDRESS D LOCATIO jn ------------------------------------------------------ <br /> Owner's Name ---- <br /> _ -- ---- - Phone-------�^�---------- <br /> J <br /> Addressf - . -- <br /> -- <br /> Contractor's Name----- ---- --- ----- ---- ---- ---- ------e------------------------------ ------------------------------- Phone--------------- ----- <br /> Installation will serve: Residence []Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Ot er ❑ <br /> Number of living units: _Xommunify <br /> umber of bedrooms __Z_ Number of baths --- _- Lot size __ _ _!/_ __� _ _ __________________ <br /> Water Supply: Public system system F❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam E] Clay ❑ Adobe IQ/Hardpan ❑ <br /> Previous Application Made: Yes E] N0 <br /> New Construction: Yes o ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted i pu6lic sewer is available within 200 feet.) l <br /> Septic Tank: Distance from nearest well----�f�V6_ istance from foundation____V----.__.Material---------------------_"�______ _ <br /> No. of compartments-------------k-------Size- - - _ `-----Liquid d p`th----------- <br /> --------- <br /> Capacity------ -— _r-- <br /> Dispos Field: Distance from nearest we� Distance from foundation-.-A-WK.—Distance to nearest lot line_ __ <br /> t � i i <br /> Number of lines_______________r_�_r _Length of each Isne____�____ ________Width of trench_____-_-_- __� <br /> 11 -- Total length----------- t. -�.--=--- <br /> Type of filter material�_� ____-_ _Depth of filter material____.__�__�_____ <br /> Seepage Pit: Distance to nearest well_""_____________._Distance from foundation-----/_..a--------.Distance to nearest lot line----;`_________. <br /> Number of pits------r_--------------Lining material__ r__ c__Size: Diameter__.....7 ----------Depth <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_--_--.-________-____________.______. <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> F1Distance to nearest lot line---------------------------------------------- --•-•-•--------------------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe)----------- -----------------------------------------------• .................----............----------------------------------------------•------------- <br /> ------------------------------------------------------- -----------------------------------------------------------------------------------•••­­----------------------------------------------------------------------------- <br /> I <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 laws,-and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)-- -- -- • ..1.4 v---Olt--- -- -- ---- •------------------------------------- - -----------------------------------(Owner and/or Contractor) , <br /> By:-----------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- <br /> (Plot 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 /> APPLICATION ACCEPTED BY- DATE--�/�--------------------------------------•-----_------ <br /> REVIEWEDBY-------------------------------- _ DATE- ' ------------------------------------------ <br /> BUILDING PERMIT ISSUED <br /> ISSUED-_-----•--------------- -_Alterations and/or recommendations:_____' � 0,4 -- '�_ <br /> ----------------------------------------------------------------------------------------------•-------------------------------------------------------------`-`--�-"---.---- <br /> ---------------'--------------'- <br /> -------------------- <br /> ----------------------•------=---------- -------------------------------------------------------------------- ----------------------------- --------------------------------•----------------•------------------------------- <br />} -------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------- --------------------------- <br /> ------------------------------------ ---------------- ---- <br /> - ----------------------------------------------------------------------------------- - <br /> I 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 8-5E Revised W-2100 <br />