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!APPLICATION FOR SANITATION PERMIT Permit No. _?&A.3_ <br /> �j (Complete in Duplicate) 3lj lS C/ <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 application is made in compliance with County Ordinance No. 549. + <br /> JOB ADDRESS AND LOCATION / '. C��-�------------------------------------- -------------------------------------------------•------------- <br /> Owner's Name------- ----------- Phone------------- -------------------- <br /> Address----------- <br /> -------- ---Address----------- <br /> - ----- - -------------------------------------------------------------------- ------------- - -- - ------------------------------- <br /> Contractor`s Name__________________ <br /> - - -- ---- ---- - -- - -- ---------------------------------------------------------------- --------------- Phone--------------------------------- <br /> Installation <br /> ----- •----- -- - -------Installation will serve: Residence , Apartment House ❑ Commercial ❑ Trailer Court ❑ Motet Other ❑ l <br /> Number of living units: _/ZPNumber of bedrooms Number of baths/VLot size ---o4 41ko, �__________________________ <br /> Water Supply: Public system I Commun'ity system ❑ Private ❑ Depth to Water Table 61_ ft. <br /> �i <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe g?'01Hardpan ❑ i! <br /> Previous Application Made: Yes ❑ �No New Construction: Yes ❑ No [4�HA/VA: Yes ❑ No 9} <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material------------___-------------------___._.________- <br /> ❑ No. of compartments-------------------i Size--------------------------------Liquid depth------------- ------------Capacity---------------------- <br /> 5 __________Distance to nearest lot line-- <br /> Number <br /> __..__. <br /> d: Distance from nearest welt._.._ -...Distance from foundation__ __+_ a} <br /> Number of lines__ _______.._ __ _-_____-__ Length of each line______ `_`____________-Width of trench : __ _____________ ! <br /> Type of filter material---�� °��-Depth of filter material--- '.--___Total length____.-90P---------------------------- <br /> e <br /> ------------ ! <br /> -------------- <br /> 4e —. Distance to nearest well---------=------Distance from fou ation___-?J9__f___.Distance to nearest lot line--fP ---- <br /> Number of pits---- __Linin material,/� Size: Diameter___ _! Depth____ _'____`__________ <br /> P - - g `' <br /> sspoDistance from nearest well-----------------Distance from foundation--------------------Lining material--____.__________________-___________. <br /> ❑ Size: Diameter------I----------------------- ------ Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well ___-__--------_----------------------- ---------Distance from nearest building______.____________-_.---_____________._. <br /> ❑ Distance to nearest lot fine__________----------------------- <br /> ----- <br /> ------ ----------------------- ------------------------------------------------------------------- <br /> � � <br /> Remodeling and/or repairing (describe):------------------- ---------:�Vt -------------------------- <br /> i <br /> ---------------------------------------------------------------- ---=-----------------------•--•----------------------------------•-----------------------=----------------------------------------------------------------- <br /> j <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 andlregul tions of the San Joaquin Local Health District. <br /> 4(Signed) '� � -------- ------ Contractor) <br /> By:---------- ................................... ----- <br /> -----------------------(Title)- ------------ <br /> (Plo# plan, showing size of lot, Iota#ion system in relation to wells, buildings, etc., can be placed on reverse e). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------- ----------------- ------------------------------------------------------------------DATE------------------------ ------- ------------------- <br /> REVIEWED BY---------------------------------------E _ DATE----- ------------- . _----- -•------- <br /> -------------------------- - -------------------------------------- - <br /> BUILDING PERMIT ISSUED------------------- ' - -- -------------------------------------------------------------- DATE-- <br /> Alterationsand/or recommendations--- --------------- ---------------------------------------------------•--------•-------•--------- —----•- ---------------------------------------- <br /> -•--- ------------------------•-------------------------------------------- ------------------------------- --------- <br /> - -- -------------------------------...------------------------------••----------•-------------------- <br /> ----------- = _ <br /> ----------------------------------------------------------------=--------------- <br /> ? ---- _�_:�:e....a- ------- �� ---------------------------------- - ------------------------------ <br /> � r <br /> --s� <br /> FINAL INSPECTION BY:.._ = �-------- Date. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M , 'Reviseci 1-57 r.P,CO- <br />