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Aw <br /> G' APPLICATION SANITATION PERMIT Permit No ' <br /> y VN �� ,�' FOR E • -•----. ...... <br /> (Complete in Duplicate) <br /> Date I*ed <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work {sarin described. <br /> This application is made in compliance with County Ordinance No. 549. 11 <br /> �, <br /> JOB ADDRESS AND LOCATION- �.a__;AP_..... �'L.�/ - ----------------------------------------------------------------- <br /> Owner's <br /> ----- ------------- •--- ----- --- <br /> Owner's Name.......... . ---=-- ---------------------------------------------------------- -------- Phone_ .------. ------......------ <br /> Address •-- - ----- ---------------•--------------------------•----------- <br /> Contractor's Name---•-- ��.__ ---_-- ........--- ----- --- ---------- ------------------------------ Phone-._---- .............. <br /> Installation will serve: Residencepartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 1�1 <br /> Number of living units Number of bedrooms 2l--Number of baths 1-__- Lot size ._ ?._ '- • - <br /> Water Supply: Public system ❑ Community system '❑ Private �epthto Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ❑ Clay m-❑ Clay❑ Adobe j,--HardpSn`D`yY <br /> Previous Application Made: Yes ❑ No lew Construction: Yes <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> i <br /> Septic Tank: Distance from nearest wel6Ze:e _-Distance from foundation----------------- -.Material <br /> "�' No. of compartments _ � riq depth _' ------ Capacity.y �.e. <br /> f <br /> Disposal Field: Distance from nearest wel4 __.Distarfce from ioundatio u'�_ ,r_.___.Distance to nearest lot line_.._-_ <br /> Number of lines... = 77ff- .5,,-.J__ Length of each line ___r_ / ___.Width of trench. ,2:4-'" __.-_ <br /> Type of filter material---L!�•--x—_Depth of filter, material_-f -C--------Total length--------�Q � -�- -' <br /> Seepage Pit: Distance to nearest well____________ ________Distance from f6rundation _-._- ------_•.Distance to nearest lot line___-______---____ <br /> ❑ Number of pits_______ _________Lining material-_____ ___________-__Size: Diameter___.-..---_-_ _--_.__.Depth-----------------------_------- <br /> Cesspool: <br /> ___--________-_--•-____--___- <br /> Cesspool• Distance from nearest well__ ____________Distance from foundation_____-------------- ,'Lining material-----------_-- ........... <br /> ❑ Size: Diameter----- -------- �( epth..;. ••--• - =- ----� -----------------Liquid Capacity --------- ...........gals. <br /> Privy. -- - -`Distance from nearest well_____-__ _ ________________ _______-_ __Distance from nearest building--------------------------------..._.......... <br /> ❑ Distance to nearest lot line---- ----- - -------.......... _-- -------------------------------------------------------------------- <br /> Remodeling <br /> -------------- • ----- --------Remodeling and/or repairing (describe :------ ---- - �' !� ` - - ..... <br /> --= --' I:.----------------------------------------- <br /> --------------------------- ------------- •-•-..........................---•--------- -------- -------- ------- ----------------- --- --------------------------------------------------- <br /> I <br /> -- ----•-- -------- ------- ------ <br /> hereby certify that I have prepared this application and the+ the work will be done in accordance with San Joaquin County <br /> ordinances, S+ate s, and rules And' regulations of +he San JoaquinocaI Heal+h District. <br /> ,Jr(Signed)... ------ - ~ ---- ---------------- -- - ------- <br /> - - (Owner and/or r Contraotor) <br /> BY ------ ------ ----• --------------------------------- --------»-----------------------------------------------(Title).--- -------- ----------------------------------------- <br /> (Plot <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 ------ ----- -•-- --F -----------------------------------......... DATE_ ------- a"� �--�' --_- <br /> REVIEWEDBY--------------------------------------------------------------- ----- ------------------------------------------ =-• DATE------------•---_-------------------------•---------- - <br /> BUILDING PERMIT ISSUED...................................----- ------ - - -- ------ DATE•. _ <br /> Alterations and/or recommendations-- ------------ ----- -------- -------=- ----- --------- ----- -- -----_ --- ---- ----- ----•••-• ---- • •----- <br /> ----- ----- -- --- > ----- - - --- ------.- --- ----------------------------------- ----- - - - --- -- --- <br /> -------- ---•.... ....--- -- <br /> FINAL INSPECTION BY:........ ......`i''' P <br /> --------- ---�"--"................... 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 8.51 Revised W-2100 <br />