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APPLICATION 4 FOR* SANITATION PERMIT Permit No. ;7.�... <br /> ./ (Complete in Duplicate) <br /> Date Issued <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 applicatiori•is made in compliance with County Ordinance No. 544. <br /> JOB ADDRESS AND LOCATION------- 3 8I y -------------------------------------------------------------------- ---------- , <br /> v r .R �. <br /> Owner's Name------------A- - -• --------- '--- C- 1 4- ----------------------------------- ------ Phone-----•---------....:...------------- <br /> Addressa -= ------------ -�- �-------------------------------------------------------------------------------------------------------------- <br /> Contractor's Name ,e- _t�___ ..d ----------------------•--------------------- PhoneAA,4_-_ <br /> Installation will serve: Residences rtment-House.❑TCommercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __! rNumber of bedrooms _ _ Numberyof baths -_/-_ Lot size --------------------- <br /> ______________.____,� <br /> 1f - <br /> Water Supply: Public system ommunity system El Private j1 Depth to'Water Table _y4._ ft. \ <br /> Character of soil to a depth of 3 feet: Sand;❑,Gravel '❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [ Iardpan\L� <br /> Previous Application MadeYes'+❑ No [- New Construction: Yes �lo ❑ FMA/VA: Yes ❑ No E] <br /> TYPE OF INSTALLATION iANDISPECIFICATIONS: F <br /> (No septic tank or'cesspool permitted if public sewer is available.within 200 feet.) <br /> Septic Tank: Distance 'from_ nearest well_372�.--_____Distance from foundation-JO I_(�______ _______________ <br /> # p .� ---4---------Liquid depth. ----Capacity-••-�O- -"--- <br /> Nn. of com artments______..___a_'Z___________Size___ __ ______ y'" <br /> Disposal Field: Distance from nearest well...6_P_'___-Distance from:foundaticn_.__,/_4"-----Distance to nearest lot line_____-�Q_� <br /> Number..of lines-----------/------______ ____ Length of each line_____%Q_'___________.._.Width of trench______�_V-----__.-___._____._ <br /> Type of filter material__S'i._A_ _ Depth of filter'materi �_,,C ___;Total length-__._��_-!i_1-___________________________ <br /> Seepage Pit: Distance to nearestwell_JDD_.._______Distance fromfoundatiori::___/___ ____._..Distance`to nearest lot lined-------- <br /> � i ! �' - -? <br /> 1R`/ Humber of pits.---/-------------Lining material- ----Size: Diameter-----3 _------.----.Depthr�0...--------� ---:----_-__-- <br /> Cesspool: Distance from nearest well-----------------Distance from .foundation--------------.-.;_.Lining material___________.___.______.___-_____.____ QS1 <br /> Size: Diameter--------'------------------------------Depth----------------------------- I------------=-------Liquid Capacity gals. <br /> Privy: Distance from nearest well_____________________________________ __ __-___Distance from nearest buildin d <br /> ❑ Distance to nearest lot line--------- ----- - - --------------------- -----------_-----•------------ ----------- <br /> ------g----------------------------- ---------- <br /> Remodelingand repairing (dascri}ae)_--------------------------------------------------------------------------•--------------------------------------------------•- --------------------- <br /> f <br /> -- <br /> I. <br /> --------------------------%---------------------------I----------------------------•------------------------------------------------------------------------------------------------------- •-------------------------------- <br /> I hereby certify that I have!prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinanc s Steffe-laws, and rules and regulations of the San Joaquin Local Health District, <br /> (Signed) .......4��--------------------------------- ------------------------`-----------=---- -------Owner and/or Contractor) <br /> By:-------------------------1 �. _! i– ------------•------ -------------_----------{Tit{e) 1------ ---------------- <br /> ---------------------- <br /> (P[ot plan, showing size of lot, bca+ion of sys a in relation to wells, buildings, etc., can be placed on reverse side). ' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By--------------------P <br /> -- - -- � x� DATE-_-------_-_--__ <br /> REVIEWED BY - f ---- - DATE 7---------------------------- <br /> -- <br /> BUILDING PERMIT ISSUED----- -r------: DATE. <br /> -------------------•---- <br /> Alterationsand/or recommendations:--------- ----- --------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------•----­­1-------- <br /> ------- ------- -----------------------•-------•-----------------•----------------.-------- -------------------•--- <br /> ;= - !----- ------------------------------------- --------------------------------------------------------------- ------------------- ---- <br /> ----------- <br /> ---------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION- BY _ Dafiej.- <br /> I <br /> SAN JOAQUEN 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-4---2M Revised 1.57 F.P.CO. <br /> r <br />