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r <br /> Permit No. _------ <br /> APPLICATION FOR SANITATION PERMIT '] <br /> (Complete in Duplicate) Date Issued771__?__ <br /> Application is hereby made to the San Joaquin. Loe-al Health District for a permit to construct and install the yvork herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> ------------ <br /> = <br /> ------------------------------------ <br /> =F <br /> �•--------- ------------- <br /> JOB ADDRESS ANQ_ OCALN : - Phone <br /> Owner's Name____________ -----------------• - ---------- <br /> f+ <br /> /_ -...---•fu�F---- ,4C_e�! '`�fe!_..e�.j--- `----"'�-:`.`�L=�s€- --------------------------------------------------- i <br /> Address--------------_----------•-------- <br /> Phone------- --------------------------- <br /> ------------------ ------ <br /> Contractors Name----------------------- - ' <br /> Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ ' Mo e1 ❑ Other El <br /> Number of living units: ---/___ Number of bedrooms __ __ Number of baths Lot size __--gd_�- •-.;- <br /> Water Supply: Public system ❑ Community system ❑ Private ® Depth to Wafter Table __6'_ ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel ElSandy Loam ® Clay Loam [I [jClay Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No IA New Construction: Yes ® No ❑ <br /> 1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) / <br /> ---Distance Distance from foundation__�C1__---- F <br /> Septic Tank: Distance from nearest well---- - . <br /> � r - <br /> No. of compartments---------�"---- 5ize_1�� Liquid depth----3------------- ----Capacity-- ---� ------- <br /> k <br /> Disposal Field: Distance from nearest well._. 1�_-___Distance from foundatian�_ d__._____..Qistance to nearest lone_-- -----• <br /> ® Number of lines----------- ----fy- Length of each line.....-�rte-------I-------.Width of trench- --- -----�------------------ <br /> Type of filter material--- of filter material_-_.l�f----------Total length___--1-49��----------------------- <br /> Seepage Pit: Distance to nearest well------------------_---Distance from foundation___.____-_.__-.__Distance to nearest lot line----------------- <br /> Number of pits----------------------Lining material-----------------------Size: Diameter-------------- ------- Depth-- -------------------------- � <br /> Cess❑poo4: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- <br /> -Liquid Liquid Capacity- --------------------------gals. <br /> ❑ Size: Diameter-------------------- -----.------ <br /> ___._Distance from nearest building_______-_.___________________________ <br /> Privy: Distance from nearest well--------------------------------------- - - 4 <br /> Distance to nearest lot line---------------------------------. ----------•--•------- <br /> ----------------------------------------------- C <br /> El <br /> Remodeling and/or repairing (describe :-------------------------- --------- ---------•------------------------•-•-- <br /> ----------- ----------•------------------------ <br /> ------------------------------------ ---------------------------------------------------------------------I-----------­--------------w-------------------------------------------­_­------I------------------ �y <br /> ---------------------------------------------------------- <br /> - ------------------- --------------------------------------------------------------------------------------------------.----------------•----•-------------------------- --- fi <br /> -I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ------------------------------------------ <br /> - <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. IF <br /> ------------------------(Owner and/or Contractor) <br /> (Signed) r,� l -- --•• --------- ------ <br /> rt e <br /> By---------------- �-•�---- ------------ - --------------------------------- fc., { 1 --- - <br /> i (Plot plan, showing size of"lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> F �gTMENT USE NLY <br /> APPLICATION ACCEPTED BY--- '-- -- ----- --- '- .- <br /> --- DATEf�` <br /> REVIEWEDBY----------------------------------------- ------------ --------------------- <br /> ----------------- DATE <br /> PERMIT ISSUED------------- ------------ ---------------------------------------------------------- <br /> ------ DATE------------------------------------------------ '------- <br /> Alterations and/or recommendations:---------------------------------------- -----------•----•-------------------------- <br /> ------------------------------------ <br /> -------------------- <br /> l <br /> FINAL INSPECTION BY:.. _ ----------------------------- Date 1 1 <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 814 North "C" Sfree+ <br /> 13o South American Street 300 West Oek-Sfreet 132 Sycamore Street <br /> Stockton, California <br /> Lodi, California Manteca, California Tracy. California <br /> ES-9-2M 10-52 Revised'-W-2100 <br />