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Q <br /> APPLICATION FOR SANITATION PERMIT Permit Nv.J�v-, <br /> (Complete in Duplicate) <br /> Date Issued <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. c/ <br /> JOB ADDRESS AND LOCATION-------5,3-7-- ' - ------------------------ f ---------------------- <br /> Owner's Name----- Phone �'� 7 <br /> Address ? '2 ' / -----------•--- <br /> Contractor's Name..... -�"-- --------------------------------------------------------------=---------------------------------- Phone.l <br /> Installation will serve: Residence 0----Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _/__ Number of bedrooms ._ _. Number of baths Z__- Lot size ...... <br /> Water Supply: Public system RI -'Community system ❑ Private ❑ Depth to Water Table yr ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No �ew Construction: Yes E-'No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if ublic sewer is available within 200 feet.) <br /> �j,, � i <br /> Septic Tank: Distance from nearest we /Lem-.Distance from foundation----Ze--_-----.Material--_C_s�------'`+'"'---"_'--- ---------- <br /> No. of compartments--------n-------------Size_$ ~-YVA------------Liqu��'p? h__,_,�-�-------------Capacity---P Si <br /> Disposal Field: Distance from nearest well Distance from foundation....................Distance to nearest lot line-______.._._..... <br /> [� Number of lines------ Length of each line../Wo 1_.__....._.._.Width of french-----i� _��------____________ <br /> Type or' filter material__S�__ 4 .Depth of filter material_.___l$�_-'_______Total length___. d�...................... tf1 <br /> Seepag it: Distance to nearest well-----Z------------Distance from foundation.._3d ..__.Distance to nearest lot <br /> [v] Number of pits___ _ ____________Lining mate ria l_.yXB' Size: Diameter-___---4- e.'.-_._.Depth_-___-2- ' <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---_----------------- <br /> Lining material---------.___-_______-____________-_. <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity--- _-----------------gals. <br /> Privy: Distance from nearest well _________________________-----------------------Distance from nearest building----------------.------------------_...... 1 <br /> ❑ Distance to nearestIllot line----------------------------------------------- ------------ Ib <br /> Remodeling and/or repairing (describe):........................................................................................................................................................ t� <br /> ro <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 /> -_ <br /> (Signed)........ ............. ---------------- �----------------------------------------- ----- ----(O r and/or Contractor) <br /> ... --------(Title)------ ------------- <br /> By: = � <br /> (Plot plan, showing size of lot, location of system in relation tow , buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- k <br /> ----------------------•_.. DATE•••-J ;?REVIEWED BY---------------------------------------- -..-------• ----------------------- --------- --•---------••--••----••.. DATE........................................................... <br /> PERMITISSUED...................................................................................................... DATE--------------------------------............................ <br /> Alterations and/or recommendations:_._.___-__ _._ _____. <br /> �.. D��> ...............•----------- -------------..-:---------------- <br /> ---- - <br /> ---------------------------- --------­----------y-­--------------------- .....................................................................................I <br /> ------------------------------------------------------•-------------------------------- ---•-----------...---------------------------------------------------------------•---•--------------...........•-•--...-••••------•-- <br /> ------------------------------------ ----------------------------•-------•-----------------------------.•--•.....----•-•--...---- ---------••.------------------------------------------. •-_...---•-- <br /> 0 ff v/ <br /> FINAL INSPECTION BY------------------- -----N--�-�---�------------- Date-------- -------- -------5---------------------------------- <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 />