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Per <br /> No,d <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> Dat Cl --- -----..--/--� <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 <br /> application is made in compliance with County Ordinan e No. 549. <br /> JOB ADDRESS AND LOCATION------------- 0-----I S-4­,�,_,j,, _ '_ <br /> Y---------- <br /> ------------------- ------------------------------------------ <br /> Owner's Name---------------------------------------------J CIG.I f: --------- —----------- -------- Phone----- ------- <br /> Address-------------------------------------------------------- -----_------ _------------------------------------------------------------------------------------------------------- <br /> Contractor's Name--------------------------------------P'no-n-,x ---k--- -C..-----•-------------------------------------------------- Phone-------97_yJ6__C!/------- <br /> Installation will serve: Residence [X Apartment House E] Commercial ❑ Trailer Court [] Mofel E] Other 0 <br /> Number of living units: ----!.- Number of bedrooms _-_E--- Number of baths Lot size ------2- -------------------- <br /> Water Supply: Public system E] Community system E] PrivafeX Depth to Wafer Table 17(o ft. <br /> Character of soil to a depth of 3 feet: Sand [] Gravel E] Sandy Loam E] Clay Loam Ej Clay E] Adobe,8 Hardpan ❑ <br /> Previous Application Made: Yes E] NotR!I_ New Construction: Yes j< No E] <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-74P--'0 <br /> ------Distance from foundation' ---------.Material---_ _ _ - <br /> No. of compartments-----ki---------------- ------------- <br /> Liquid depth__ :_"ep�h__Z7�V,_"------ --- Capacity _-------_-- <br /> ------------ <br /> - <br /> fixe - <br /> Disposal Field: Distance from nearest well ..2-0.....Distance from foundation------------_----_.Distance to nearest lot line-.5----------- <br /> Number of <br /> lines----_1-------------------------Length of each line----- --------Width of trench.-P'-.'-_"J---------------------- <br /> Type of filter material--- .-.._-Depth of filter material--------'107"'______Tofal length..--r0-j,'7-'`-------------------------- <br /> r <br /> ength....j0t�,_j,'7----------------------------- <br /> Seepage Pit: Disfance to nearest ---Distance from foundation--- Distance to nearest lot line----IC-11---- <br /> IN Number of pits---- -----------------Lining maferial-e-zli-':_,�-----Size: Diameter------1=�1_3. ...... Depth--.*? <br /> ---------------------- <br /> Cesspool- Distance from nearest well-----------------Distance from foundation--------------------Lining material--.-----------------------.--_.__-__ <br /> ❑ <br /> aterial------------------------------------- <br /> El Size: Diameter------------------------------ ------ Depth----------------------------------------------------Liquid Capacity------------------ ---------gals. <br /> Privy: Distance from nearest well---_----------------------- --------------------Distance from nearest building_----------------------_-_ <br /> -------- <br /> ElDistance to nearest lot 1ine--------------------------------------------------------------,--------- --------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):------------------------------------------------------------------- ----------------------------------------------------------------- ------------------- <br /> ------------------­-------1-1-------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------- <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, SfaUdAaws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)----------- ------t. ----------------- ------- tMne"ntlOw Contractor) <br /> ------------------------------------------ <br /> By:----------------------------------------------------------- -------- --------- ":��--------- -------------(Title)--- �44–--------------------- <br /> (Plot plan, showing size of lot, location of system in kelafion to wells, b4ildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--"-- DATV --------------------------------------------------- <br /> REVIEWED <br /> -------------------- ------------------- <br /> - <br /> ------------------ <br /> J6---- <br /> kEVIEWED BY - ----------------------- ---------- -------------------------- --- DATE-_ o&------- <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------- <br /> Alterations and/or recommendations:---------------------------------------------------------------------------------------------------------------I----------------------------- --­------------- <br /> ---------------------------------------------------------------------- ------------------------- - ---------- -------------------------------------------------------------------------------------I-------------------------- <br /> ------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------- ----------------- <br /> ------------ -------------------- --------------------------------------------------------------------------- ---------------------------------------------------- ---------------------------------------------------------- <br /> FINAL INSPECTION ----------- Date-.. <br /> ------------- -- ------------------ -------------------------------- <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 /> ES-9-2M 10-52 Revised W-2100 <br />