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3" APPLICATION FOR SANITATION PERMIT _ Permit No. .. .... <br /> t p (Complete in Duplicate) <br /> Date Issued ___f_ __..-_�� <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 Ordina e No.3 --- <br /> 549. <br /> rr <br /> - -o--p-- <br /> JOB ADDRESS AND CATION c) <br /> r� ---------o--- _.. - �- <br /> ------------- --- -` __ / Phone ' <br /> Owner's Name________________ � - <br /> Address - - i'v 11 1- <br /> --------------------.......----------------------------------------------- <br /> Contractor's Name----------------------•--------- ----------------------. _rr e <br /> -----------------------------•-------------------------_ Phone----------------------------------- <br /> M- Installation will serve: Residence Apartment House El Commercial [-] Trailer Court [3 Motel ❑ Other ❑ <br /> Number of living units: ___ ___ Number of bedrooms ___1__ Number of baths __/--. Lot size _______j - - - ------------------------- <br /> Water Supply-I Public system [ Community system ❑ Private ❑ Depth to Water Table _-_____ ft <br /> Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam ❑ Clay,❑ Adobe LIQ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No e New Construction: Yes Loam <br /> ❑ -� <br /> i pP : l <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> `e' �p------Material_�__c-mC ' ' '- <br /> Septic ank: Distance from•nearest well__- Z_ Distan fro fours ion________ <br /> No. of compartment - s2- ------Size--- <br /> depth------_�---- -------Capacity------i&spiv <br />' Fes- f t ,� <br /> Dispos Field: Distance from nearest well Distance from foundation____ D____._-.-.Distance to nearest lo}�ine____.,J.__.___ <br /> Number'o{ lines-; - 30--- ---Length of each line----- - - -`---..Width of trench.-----,�5._ -____-P_____________ <br /> Type of filmaterial----- ' _ _---------Depth of filter material_'-_- _2--------Total lengfh-- ------ ----------:------- <br /> i <br /> Seepage Pit: Distance to nearest well_.________________---Distance <br /> from foundZe:nDiameter=:-D�stance to nearest lot line_______._____-_.. <br /> Number of its-=--------------------Lining...material-•---�------ ___.----- -�- --.Depth-------------------------------- <br /> Cesspool: Distance from nearest well________________ Distance`,from foundation_____.______---___-.Lining material-____-._.____-_-_______.__-_____--_ <br /> Size:,D_iameter--- ----- ------Depth----L ---- --------------------- <br /> El <br /> Liquid Capacity _ gals. <br /> _-' - <br /> Privy: Distance from nearest well__________ ________ _______ _ __________ Distance from nearest bJ mg___`__. _---- ---------------------------- <br /> El <br /> ______________ _.-_-_. <br /> ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe):---------------------- ------------------------------•----------------------------------------------------------------------------------------- --------- <br /> 1 <br /> -----------------------------------------------------.------- ------------------------------------•-------- <br /> { <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, Slate laws, and rules an regulations of the San Joaquin Local Health District. <br /> (Signed)----"showingsize <br /> --------- ----- -- - ------ --------- -- --------------------------------------------------------------------(Owner and/or Contractor] <br /> 1 Tale <br /> (Piot plan, ot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY---------------- - ------------------------------------=----------------------------- DATE------- ---------------- <br /> REVIIWED BY ----------------------------------------- DATE --------------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------- -------•----------------------------------------- DATE-------------------------------------------------------- <br /> Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------..----------------------------- <br /> ----- <br /> -------------------------------------------- -----------------------------------------------•­------------------------------------------------------------ <br /> --------------------------------------- ---------------------------------------------- ------ ---------•-------------------- -•---------------------------------------------------------------------------- - <br /> a <br /> --------•-------------- ---------- <br /> FINAL INSPECTION BY:------ -'--------------------------------- Date--------- -'-----1'--`r--------5_3------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> *. ) ).:�t it ! 4 <br /> 13D South American Street 300 West Oak'Street, <br /> 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 + <br />