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14Ia APPLICATION FOR SANITATION PERMIT Permit No. __SP__________ ___ <br /> (Complete in Duplicate) <br /> r Date Issued ... <br /> Applica{ion '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. r ; <br /> JOB ADDRESS AND ATI • l f =---�6'' �=--- {' n = <br /> -- <br /> Owner's, Named' - _ --------------- Phone----------------------- <br /> --- <br /> �2 <br /> ---- �' l > _--- `�� �1 � �'= ----- ---------------- <br /> --------------- <br /> Address <br /> Contractor's Name , "= moi. - ----- ------- �� �- f Phone--,4_�---4_ P_�:_� <br /> Installation will serve: {Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___ Number of bedrooms __ Number of baths ---(.-_ Lot size - --x <br /> Water Supply: Public',system M_ Community system ❑ Private ❑ Depth to Water Table <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel.❑ Sandy Loam 0 Clay Loam [] Clay ❑ Adobe[a, Hardpan ❑ <br /> Previous Application Made: Yes ❑ No V New Construction: Yes No ❑ <br /> 4 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ' <br /> No septic fanVor cesspool permitted ifppublic sewer is available within 200 feet.) <br /> r Y r �s. �o <br /> Septic Tank: Distance from .neares+ well__ �? Distance foundation <br /> uid de th-_Material r <br /> No. of compartments - _ Size_____ __ !~1 0*1 �y <br /> P q p. Capacity 76� -- <br /> Disposal Field: Distance from nearest well---�p1L Distance from foundation)A_ _`•-___Distance to nearest lot Iine.�/A____. <br /> �c Number of lines____________.-______--0-c--Le of each line__________, 6______ _.Width of french------��---__----------- <br /> --------------------- <br /> Type-of <br /> _________ <br /> Type"of filter material-______-- pth of filter material___:._,__g___.___Total length_.__,___ _____________________ �p <br /> _ g. _ y. _ ria4f / l <br /> Seepage Pit: Distance to nearest well___!' -13istance from foundation__ __ ________'_.Distance to nearest lot line____ _______ <br /> Number of its._._ ._ _____Linin material�_e'>..&�f Diameter_:_� __-_.___._.Depth_____ ��___o_______________ <br /> Cesspool: Distance fo�orn nbarbs+ well-----------------Distance from foundation_='-__',_',.w_ _---:Lining material___.__-_------------_---_____________- <br /> ❑ Depth Li u.id Capacity ----- gals.Diameter-------- -------------------- -------- ---------------- - = `---------- L <br /> T <br /> Privy:' Distance from nbaresf well------------------------------- -------------- --Distance from nearest building------------------------------------------ <br /> ---------------------------------------------------------------------------`- . -w_;. --Distance to nearest lot line--�" �=-- t. -"* �- - "�-- ^._` . " <br /> ------- ---------------------------------------------------------`---------- <br /> f <br /> Remodeling and/or repairing (describe): ---------------=� - <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 /> ws, and rules%and regulations.of the San Joaquin Local Health District. <br /> ordinances, Stat <br /> (Signed]Br• ' <br /> �-� LL2GA ------------------_----------------------------------------- <br /> __ __ <br /> f (Owner and/or Contractor <br /> ----- (Title)---------- ---------------------------- <br /> F <br /> --------------------------- <br /> 'G � <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 t � <br /> APPLICATION ACCEPTED BY------- ---------------- - -------= =-------------------------- DATE------- <br /> �71---- ------------------------------------------ <br /> REVIEWED BY---------------------- <br /> -----_----------- <br /> ------------ = = DATE <br /> BUILDING PERMIT ISSUED------ ------------­-----­---- -----------:-------------------------------------------- DATE----- •. -- --------------------------------:-.-.-.-.-.-.-.-.-. <br /> Alterations <br /> -- --- ------=----....- <br /> Alterations and/or recommendations:-:--------------------------�--------- = = -- --------•- ---------------- <br /> -------------- <br /> -------- <br /> 4 <br /> - �r ` <br /> t <br /> ----------------- --------- - -- ------------------------------------------------------------------------)-------------------------------------------------------------------------------------------------- ------- <br /> FINAL-INSPECTION-BY:---—. Datet ^- � -------------------------_------------------ <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street- r- 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ; Revised W-21o0 <br />