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t�r,11 <br /> APPLICATION FOR SANITATION PERMIT Permit No•{Complete in Duplicate), /p S� <br /> Date Issued ._-----•-- <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct and install theerkFereln d scribed:.,- <br /> This application is made in compka1nce with County Ordinan e No. 519. <br /> - <br /> JOBADDRESS AND LOCATION----------- ---�------ ------•------------------ ----------------------------------------- <br /> Owner's Name - ------ ---- PhoneI <br /> Address-----___. <br /> 71 ----------- '. , ---- - -------------------------•----------------------------- = <br /> - ? , �A - <br /> Contractors Name---- Phone Q <br /> Installation will serve: Residence jg Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -`A Number of bedrooms __ - Number of baths _/___ Lot size ___-______ , ---------------------------------------- <br /> Water <br /> _K___----_---- __________________Water Supply: Public system Z )Community system ❑ Private ❑ Depth to Water'TA6I y'0_ ft: <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ;[ New Construction: Yes M No ❑ <br /> TYPE.OF INSTALLATION 'AND SPECIFICATIONS: <br /> (No septic tank or cesspool'permitted if public sewer is available within 200 feet.) <br /> t R o(,cJe! T' d� <br /> Septic Tank: Distance ,from nearest well N--_-_-__- Distancg,frorjl foundation__=_____-----------Material--- _________________ _ _ <br /> a. <br /> No. of compartments..... .................size_,�b,X-y� ---Liquid depth___��A--_---------Capacity_ __- --- <br /> Disposal Field: Distance from nearest w�l►'__-____ "Distance from foundation��________________Distance to nearest lot Iine_ __� <br /> IN Number of lines-------------- -------- ------ ----Length of each line-----------------------_----Width of;trench--__-�i?,--•-------- •--(�a <br /> Type'of filter material__s___ _ . _ `�1 <br /> -- �. _-- ---Depth of filter material __--,- --Total length------� ____-----------------•__-- <br /> Seepage Pit: Distance to nearest well_!y-a_6j'0-/1_Distance from foundation_____ Distance to nearest lot I ne.--------------- <br /> Number of pits._____--__________Lining material�0 __.Size: Diamete`r_____�_�:.�......Dept h_.__as__�______________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation____________.-__,/`,Lining material-_________._______--_____-__-__-_-_ <br /> ❑ Size: Diameter------ =-----------------------------Depth------------------------------------------------.Liquid Capacity- - -----------------------gals. <br /> Privy: Distance from neo est well_____________-_______ __---___ __-_---_---_----Distance from nearest building--------------------------------------- <br /> L Distance to nearest'lot'line-------=----------- ------------------------- ------------------- -------aI v . <br /> 1LLyy`. <br /> Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------- <br /> �] <br /> i <br /> f 4 <br /> hereby certify that I have prepared this and }hat the work will be done in -------_-- with _____________________________ -- <br /> t s application-- - - --- - - - --- ---- - -- --- •_-_---- --_-•-----------•- accordance with San Joaquin County <br /> ordinances, State laws, and rules5and rFgulations of•fhe,San,Joaquin- Local Health District.;! <br /> bil <br /> r <br /> ,(Signed) - f�� =x�� ff -- - -------------------------------------- --- -- wner <br /> and/or Contractor)----•------------------- -- ------------ ------------------- <br /> B :.-•--e•�-i'`'�' r � ------ <br /> --------------------------------- <br /> .. -----------------------------------------------(Title) <br /> y <br /> (Plot plan, showing size of lot, locafio: of system in relation to wells, buildings, etc., can,be placed on reverse side). <br /> f FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---,I--------------------------------- f��/}� DATE----------- �_. <br /> REVIEWED BY----------------------- --- �" ----- - -�- -- <br /> - ----- -------------------------------- - - -- - ------------------------------------ DATE---------- -------------- -------------------------------- <br /> BUILDING <br /> --- <br /> BUILDING PERMIT ISSUED-------------------•-•------- ---------------- ------ DATE-------------------------------------------------------------. <br /> ------------ <br /> Alterations and/or recommendations:---- ---- .�� '` � -:---•---•--------•--------------------------- <br /> -----•-•------------------------------------------------;--------------------------------------------------------------------------------------- ------------•- -----------•-----•--- ------- ---------------------- <br /> ------ <br /> ----------•----------------•-------- ---------------------=------------------ ---- -------------------------------- ----------------__------------------------ ----- ----------------------- -----------------------------•------- <br /> 1 <br /> 3---------------- <br /> FINAL INSPECTION BY:------ Date.---- - ------- ------------------------------------------------ <br /> ! . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M I0-52 Revised W-2100 <br />