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s A , <br /> ` Permit No. ---- <br /> ^�� � {.*i APPLICATION FOR SANITATION PERM Y-� <br /> (Complete in Duplicate) �f <br /> �_'--e�\7 <br /> I1� Date Issued _._-__Applica4ion is hereby made to the San Joaquin Local Health District for permit'to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> --------------------------- <br /> JOB ----- -------------------- <br /> hone <br /> -- <br /> 7 --------------------------- <br /> JOB ADDRESS AND OCATION______�.J 4.�- ----- <br /> d,_ --------------- <br /> ------------------------------------------ <br /> -2 <br /> ------- ------------- Phone .7 <br /> Owner's Name---- - ------- - -. <br /> aY <br /> --�.� - <br /> Address - ---------------------------------------------------- <br /> --Contractor's Name - one- <br /> Ph <br /> m _ a z <br /> - ---------+J - _ f <br /> fM <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ K �. <br /> r <br /> Number of living units: _,� <br /> __._ Number of bedrooms __ _ Number of baths __ ._ Lt size _____- .- _ �� --------------------- <br /> Water Supply: Public system­;ff Community system El — <br /> Private,❑—Depth:for, ateriTable ft. <br /> Character of soil to a depth of 3 feet: Sand E] <br /> Gravel'❑ Sandy Loam 0' Clay Loam ❑ Clay E] Adobe�J Hardpan ❑ <br /> Previous Application Made: Yes ElNro New-Construction: Yes 'No ❑' € <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: , } <br /> (No septic tank or cesspool permitted if.public sewer is available within 260 feet.)' <br /> .r �... ., ,._ I. .' . .. - <br /> Distance from foundation--- - -------'..Mat :al_.__-- __ _-- <br /> Septic Tank: distance from nearest well�a_* r 00 <br /> S`/o 0 S.--Liquid.uid: de th �'� Capacity <br /> No. of compartments_ °Z -------•--Sizey_'` - q f p. �- P Y <br /> s a + / <br /> el A 04) __ g on---- _--_.Distance to nearest lot lin ---____`:S <br /> Disposal Field: Distance from nearest�ellQ �l Dtance from foundation____ _ I Width of trench------ ................._ <br /> Number of lines________! __ Len -th ofl each line______ - <br /> Type of filter material"f� -----`Depth of filter riafe�ial f _*� --_:Total length---------- s-------------- _______ <br /> S11- <br /> Seepage <br /> 1` _".Distance to nearest lot line____-Sr-__._ <br /> Seepage Pit: Distance ,o_nearest well.- .�'i� _Vistance from fou ation_.q.g4 �______ -- <br /> Linirrtg m terial-__-- _ � 35iz''e:.'A'meter----•-�.�_a-.---Depth-------/�-5�--------------- € <br /> ® Number of pits- ! ---- ----- t <br /> f <br /> R <br /> Cesspool: Distance: nearest well____.__'_:` -Distanee from faundatiori _-___.fining material_ gals. <br /> Depth ----- --- -° ---Liquid Capacity------------------------ <br /> ❑ Size: Diameter----- ------------------ -- <br /> - p <br /> Privy: Distance from nearest well__.__._.,_ " __._ _-- _----Distance frorn'nearest building__. _._.____ __________--------_____ __ <br /> ---------- --- ------------- <br /> ❑ <br /> - � Distance-to-nearest IEne.'--"-�---=--- -------�,�;;-t{;�-;� ------------------....�..��'- --------------- -------------- <br /> - <br /> : <br /> ..............; -=--=-----------------=-- ----------------------------------------- <br /> Remodeling and/or repairing (describe) <br /> ------•----------------------- ----------------•---------------- 4 <br /> ------ --------------------------- <br /> - -.------ ---•---------------------- <br /> ----•------ ---------------------------------------------------------------------------------- <br /> ! hereby certify that I have.prepared this application and that the work will be done in accordance with San Joaquin County <br /> I -ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> �^' •� � —� � ' O n�a,or Contractor{, <br /> (Signed) � "'/ GS-�C.= '' ' _------ ---------------------I------------------------(Title). . . ------. ---- u <br /> IBy:•-----------• .� . <br /> (Plot plan, showing size of lot, location of sy m in relation to wells, buildings, etc.,'can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> DATE f•,'1�`f- <br /> APPLICATION ACCEPTED BY ------ - -- --- ----f . <br /> _------------- <br /> REVIEWED BY------------- --------------------- ---- ------- --- - ------------.------------------------- -------- <br /> DATE---•------------------------------------------------------- <br /> ----------------- DAT <br /> PERMIT 1SSUED-------------------------------------------------------------------------------------- <br /> DATE--- ------- ------------------------------------------------ <br /> t ; <br /> Alterations and/or recommendations:------------------------------------------------------- ---------------•""-"""•-----`--- <br /> -----------------------=------------ <br /> ----.. <br /> 1 <br /> ------------------------------------------------- <br /> --------- ---- --- --------•----------•---------- -------------------------- -- -- ---------------- ----- <br /> Date_--_.._� <br /> i---------------Z 7 �.S <br /> FINAL -INSPECTION BY:------------ <br /> Vv <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California <br /> Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />