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a[ Xie 4:1�� <br /> qa__� APPLICATION FOR SANITATION PERMIT Permit/ y (Complete in Duplicate) <br /> Date Issued __-�/11;1 __� <br /> �1� <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:-- <br /> ---- -- ------------- -------------------------------- -- - --------------------------- ------------ <br /> Owner's Name----------------- -� ` Phone-------------------------------------- <br /> Address <br /> --------/----------- <br /> Address--------------------------�? - - ----- ---- ----------- Y " ------•------------ .----------------------- <br /> - pC-- <br /> Contractor s Name hone C1__ <br /> - - ` - -- <br /> r <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ M,otel ❑ Other El <br /> Number of living units: A-__- Number of bedrooms . -_ Number of baths _1 Lot size -------6a--f_�____/40'/_d------------------ <br /> Water Supply: Public systemCommunity system 'El Private E//Depfh to Wafer Table ft. <br /> Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam Ea/�Clay Loam ❑ Clay ❑ Adobe Eh' Hardpan ❑ <br /> Previous Application Made: Yes ❑ .No M/ New Construction: Yes [A'lNo ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> p Tank: Distance from nearest well_________________Distance from foundation-------------------Materia!________-________________-_-___--___--________- <br /> ___Li Liquid depth <br /> Se ������ ,-d-No. of compartments--------------------------Size----•----------------=------ q _ p ----------------------- <br /> Uf' ' (i 'f <br /> Disposal Field: Distance from nearest well.__ ________�Distance from foundation___________-__Distance to nearest lot 1 __�_Length of each line --____-Width of trench____�_________________________ <br /> Number of lines___________- _ <br /> Type of filter material, /__�_ _r_Depth of filter material__f_ __________Total length___` ____ _!----------------------__ <br /> 01 <br /> Seepage Pit: Distance to nearest we11-----------------------Distance from foundation--------------------Distance to nearest lot line-----------__:_:.. <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth------.------------------—=`-`-- <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------------------ "y_ -- -----------------------'----------- <br /> ------------ <br /> f--- <br /> Remodeling and/or repairing [describe):--------------- --------- ------>r� --- <br /> � r <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 re ations of the San Joaquin Local He7�1 .h District. <br /> (Signed)-.-_----------- -- 4 _V ------------ , �' `' '. {Owner`an�/or ntractor) <br /> BY� --- ----- <br /> ----------------------------- ----------------Title)------- 1 + / <br />' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- ----- DATE-------------9- --------------------- <br /> REVIEWED BY----------------------------=------ -------------------------- <br /> ----- DATE----------------------------------------------------•------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE.------------------------------------------------------------ <br /> Alterationsand/or recommendations------------------- -------------------------------------------------------------------------------------------------------------•--------------------------- <br /> r ---------------•------------------------------------------- ------------------------------------------------------------------------------------------------------------------------•-----------•---------------------------- <br /> 1 --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------••------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------- <br /> ---------------------- --- -------------- --------- --------------------- -------------------------------------------- ----- ---- <br /> FINAL INSPECTION BY:----- -------- ----------- Date a-- <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 /> I <br /> ES--9-2M 8-51 Revised W-2100 ' �. `— <br />