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/ APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> �� Date Issued -------•---.-•--�•-•- <br /> Application is hereby made to the San Joaquin Local Heafh District for a per it to construct and install the work herein described. <br /> This application is made in compliance with.County Ordinanr*e' No. 549. Dl �`2A2 ;tAr <br /> JOB ADDRESS AN OCATI N v �, _ - --- --- <br /> Owner's Name--- ----- - lel ----- Phone----=•-------------------•---------- <br /> 101- <br /> Address------------- �.�-------- - ------� ---- --+ -- � -----------------------•---- <br /> �r <br /> Contractor's Name-------- -------- ------ ---------- - ---------------------------- -`-- -----------------------------------------------------------._. Phone----------------------------------- <br /> t <br /> Installation will serve: Residence, Apartment House ❑ Commercial. ❑ Trailer Court [] Motel ❑ Other ❑ <br /> Number of living units:;_____ Number of bedrooms 3--- Number of baths I____ Lot size1_4z____________________.___._ <br /> Water Supply: Public system Community system ❑' Private ❑ Depth to Water Table -------- ft. <br /> 3 � <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob_­17T Hardpan ❑ <br /> Previous Application Made: Yes ❑ No-4. New Construction: Yes`K No ❑ FHA/VA: Yes ❑ No�K <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 well-b --------Distance from fc ndation_1n_-________.Ma eriaL _ ----------------- <br /> No. <br /> ______- <br /> No. of compartments____ ___________Size__ .}�_ _ __.__.Liquid depth_- .`T ____________Capacity_. _ _l-1_Q___.___ <br /> .-Distance from foundation____1__4,j--------.Distance to nearest lot ine.._6�____ ! <br /> Disposal Field: Distance from nearest _-` L gth of each line____�_�----------------Width of trench._ ,� <br /> Number of lines------- ---------.----------- <br /> Type`of filter material epth of filter .material___l_ _.'______Total length___-_-_, �_______________________ <br /> V <br /> Seepage Pit: , Distance to nearest well _ _._ _)_______Distanc m foundation---1_.4o-----------Distance to nearest lot linet_4�.____.._._ <br /> "`� lumber of its_ __Linin material_ ____.Size: Diameter__?_ ___________.De th_�_-5____________________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------------.-------Lining material-___.__________..___._______-------_. Q <br /> " ❑ Size:'Diameter--------------------------------------Dept h----------------------------------------------------Liquid Capacity- --------------------------gals. I <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_-_________________-___--_____._______ <br /> �❑ - Distance to nearest lot linee-------------- -=----------------------------------------------------- ------ ----------------------------------------------------- <br /> Scribe <br /> -----------------�---------------------------- '• <br /> Remod lin a&/or repairing scribe :--- --- -- _--- ---- ^.-- - •• --•-- -- -.- .,� ---------------------- <br /> �-' , <br /> � -- -- - - •-- ----------- -- --- ----•---------------------- <br /> - ------------------------=--------------17- - ------------------------------------------------------- ----------------------------------------------------------------------•---------------------------------------- <br /> ! hereby'cer+i#y'that.l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> o'rinances, a laws, and rules and regulations of the San Joaquin Local Health District. <br /> •s x � 4* <br /> (5�gned} , - --- --------------------- -- ---------------------------------------------------------------------------(Owner and/or Contractor) <br /> (Plot plan, showing size o• 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------?L---------------------------- <br /> ------------------ <br /> REVIEWEDBY------------------------------------------------------- ------------------------------------------------------------ DATE------ -----�- --------------- <br /> BUILDING PERMIT ISSUED--------------------------- ------------------------------------------------- DATE------------ ----------- -- <br /> Alterations and/or recommendations______________ I �- I <br /> ------------ <br /> ----- ---- ------------------------------------------------------------------------- <br /> • •---------------------------•----•----•--.-...-------••---•----..-----.---•--•--------••-•----.-_.--• -------------------------- <br /> -------------- ----------------15-m ��------- ca's •--------ate �- c �4i�/G `� �N( !� fa. L✓_ "; <br /> ----------------------------- = ­7--------------------------- <br /> / -��s -------�'�--------� _��� ------ � — ----- <br /> Date <br /> ---- <br /> FINAL INSPECTION BY: -------------------------- Date----------- �� � �-� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ti <br /> f30 South American Streef 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br />} ES-9-2M1 , Revised 1.57 F.P.Co- <br />