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APPLICATION FOR SANITATION PERMIT Permit No. <br /> \ (Complete in Duplicate) �-� <br /> Date Issue ...__ ._47/_. <br /> Applica+ion 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 Ordinance No. 549. <br /> J* <br /> JOB ADDRESS AND LOCATION•------✓' 7---- � -------_----5 s <br /> Owner's Name ��c .........4 ----------------- --------------------------•--------------- Phone--- ---'r�/--=.x.717--- <br /> Address......a-2.7l,12-.... <br /> ''441t--- •-------------------------------------------------------------------- <br /> Contractor's Name.........f. .' ---- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: . __. Number of bedrooms •_ . Number of baths ._7__ Lot size -_--_ S.X _ ----_ <br /> -- ----------------- <br /> Water Supply: Public system P-16ommunity system ❑ Private ❑ Depth to Water Table IV ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ 'Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 93-"Hardpan ❑ <br /> Previous Application Made: Yes ❑ No /Flew Construction: Yes [1lo❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic TaO: Distance from nearest well_��_Distance from foundation-_- Q...........Material_-G-tC'E!r � -----. <br /> / <br /> No. of compartments._--_-_-s2-------------Size.54..-_,�./d___'_...Liquid d " �•. <br /> epth-_-_-_ . .--.______Capacity._A?.0A •d� <br /> Disposal Field: Distance from nearest well_?�"__Distance from foundation........__._.Distance to nearest lot line__S----------- <br /> Number of lines---------/-----------------------Length of each line.....10 ................Width of trench------ <br /> --- <br /> Type <br /> Type of filter material.s!._Pi1 k-__-_-__Depth of filter material____-/Z-a--------Total length..........1OD' <br /> Seepage Distance to nearest well__?74?!_----Distance from foundation_...Z4 ........Distance to nearest lot line-_-.S ...... <br /> Number of pits------l-------------Lining material_yX-8___/?0.4_ ,Size: Diameter____y9----- __-.Depth-------#_25�-------------- %A <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 /> ❑ Distance to nearest lot line------ -----------------------------------------------•-----•--------------- --------------------------------------------------__ <br /> Remodelingand/or repairing (describe):---------------------------------------- ...........................................-------•------------------------------------------------------•--- <br /> ----•---------------•---------••--•-----•-------------------------•----------------------•-•--------------------------------------------•--•--------------•---------•-----•------........................................... <br /> -----------------------------------------------------------------------------------------------•--------------------...-------------------•----------------------------------------------------------------------------------. <br /> ------------------------ -------------------------------------. ---------------------------------------------------•---------- <br /> I 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)------lw"" eo�.... �DD ---- - --- ------------------------------------------------- ( caner and/or Contractor) <br /> BY� s -----(Title) •r/ ''«s'"� ��----------- <br /> (Plot plan, showing size of lot, location of syste in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- .2- ----------------- -----Q1, f -=----------------------•----- DATE----- <br /> REVIEWEDBY------------------------------------------------------ ------------------------------------------------------- - ---------- DATE---------------------•------------------------ ------- <br /> BUILDING PERMIT ISSUED----------------------------------............................... ---------------------------------- DATE...............................---...----- <br /> Alterationsand/or recommendations---- -------------------------------------------•--------•----------------------•--------•----•---......----------------• --------•-------••--------------- <br /> b )- ---- -- --------------------_--- k <br /> -----•-------------------------------------------------•-------------------------------------=-----------------------------.-.-----------------•---.......-----------------------------------------------------...------._._.. <br /> ------------ ----------- ------- --------------- .----- ------ --------------------------------------------------------------­---------- ---- -------- ........................-••---•--•-•-- <br /> FINAL INSPECTION BY:.- U :. .---------------- Date <br /> ------------------------------------------ <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 />