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APPLICATION FOR SANITATION PERMIT <br /> Permit NoJI-13... <br /> (Complete in Duplicate} <br /> a Issued <br /> Application is hereby made <br /> This parMil f* to $F San JOaquin Local Health District for a permit f c <br /> licetion <br /> Jon in co7 _7VI 4-�i <br /> iance with Count 0 d' 0 n ru f a install the work he �h clescribej. <br /> Or ina <br /> re,-y) Z:�2 b No. 549 <br /> t\i <br /> JOB ADDRESS ND CATloIF <br /> Owner's Name- ---------------- <br /> ------- --- <br /> Address­/_41.0 ► -- -- ----- <br /> �—--------------- <br /> ----------------- ----------------------------------------------------- <br /> Contractor's Name------- ------- <br /> ------------------ ----------------------- <br /> ----------- -- <br /> Installation will - ---------------------------------- --- <br /> ----------------- Phone---—--- <br /> serve: Residence'ce Apartment 0—use ❑ Commercial Ej Trailer_- -------- <br /> Number of living units: _01 --- Number of bedrooms Court.E] Motel [] OtherF <br /> Wafer Supply: Public -0- Number.of baths -4- Lo ❑ <br /> "." — --' <br /> t size <br /> system ID Community system E] <br /> Character of soil +o'a depth of Private K Depth to Wafer Table cZaft. <br /> 3 feet: Sand <br /> I X Gravel E] Sandy Loam 0 Clay Loam E] Clay El Adobe El Hardpan Ej <br /> Previous Application Made: Yes El NON,�r New Construction: Yes bf No <br /> .t <br /> TYPE OF INSTALLATION AND SPECIFICATIbNS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well"- ----".-.Distance!tom foundation""_".------F-------- <br /> No. of compartments-- <br /> az-- -------- <br /> ------------------- <br /> D�Wl Field: Distance from nearest well Liquid depth----- F-r <br /> -------- C7apacity----- __:q� <br /> _61-------Distance from foundafion_._,/49........Distance to nearest lot line-----_4� <br /> ------------ <br /> Number of lines_ Length of each line--"-""--- --------Width of french-.-, - / <br /> Type of filter material of filter material-- __ __ ---------------- <br /> - - ------------Total length---.-------1�1-- ------------------- <br /> Seep❑age Pit: Distance to nearest�well"-_- ""___ Distance from foundation----------------_" Distance to nearest lot line <br /> Number of pits."--------------------Lining material"_"___"-•" ........ <br /> Size: Diameter ......... <br /> Cesspool: Distance from nearest ---- ------- Siz ---------- DepA........... <br /> El Size: Diameter---------------------well-----------------Distance from foundation--"-"_"-_.-_ Lining material-- ...................... <br /> -----------------Depth--------- -------------------- <br /> 'Privy:. —D Distance ------------------Liquid.,S�ap <br /> a��ce,fi­6Y6 nedr6WWbllZc:i f y------------- --------------- <br /> El Distance f� nearest lot line--.,-,. ----------------Distance from. nearest building----------------- <br /> Remodeling and/or repairing (describe):----------------:------ ------------------ <br /> ------------------------------------------------------------------------------------------------------------------- ------------ <br /> -------------------------------- ------------------------------------- -----------------------I--------------------------------------- <br /> ------------------_-------------------------------------------------------------------- <br /> -- - ------------ <br /> ---------------------------------------------------- ----------------------------------------- -------------------------------- <br /> --------------- ---------------------------------------- <br /> v ---- I--------------------------- --------------------------------- <br /> I hereby certify that I have --------------------------------------------- ------------------------------------------ <br /> nc ___ <br /> e prepared this application and that the work will bed_o_r_teinaccordaewith San Joaquin County <br /> ordinances, Sfafe laws and�rula regulefions-of the San Joaquin Local Health District. <br /> (Signedj------ <br /> - ---------------ww­­------------------------- <br /> ------------(D _ _ _______ <br /> By:------------- (Owner and/or Contractor) <br /> -- s----------------------------------------------------- -- <br /> (Plot plan, showing size of 10+, location of system in relation (Title)-- <br /> ----------------- ---------- - ---------------- <br /> to wells. buildings, efc., can be placed on reverse side <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_<'� <br /> REVIEWEDBY----------- y%,k ----------------------------------------- ---------- DATE <br /> - - <br /> -----------------------------------------:----------------------- ---------------------------------- ----------- <br /> 4'�------ --------------------------- ----------------- <br /> BUILDING PERMIT ISSUED-_ ... ----- DATE----'U\ <br /> ----------------------------------------------------------------------------------------:-------- DATE--- <br /> Alterations and./or recommendations:._--------_-""--"- --------------------------------------------------------- <br /> --------------------------I--------------------------------___ ----------------------- ---------I----------------- <br /> ---------------------- ......... ......... --------------------- <br /> - -- -- - -------------- ------------------------- <br /> ---------------------------- ----------------------------------------- ---------------------------I--------------------------------I--------------------------------I----------------------------- <br /> ---------------- <br /> ------------------------------- <br /> ----------- ------------------------------ <br /> -------------- -------------------- ---- ----------------------------------------------------------- <br /> -------------------------------------------------------------------- -------------------------------------- ----------- --------------- <br /> ------------ <br /> ----------------------- - ----------------- - ------ ------------ --------- -- ------------ --------------- --------------------------­------------------------_---------------------------- ------ <br /> FINAL INSPECTION By <br /> 7 <br /> ---------------------------------- <br /> Date-------- <br /> ----- --------/_ 4; <br /> --------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 0 <br /> 130 South American Strew} _ <br /> 300 West Oak Street 132Sycamoro Stree+ OF4 North 11c*, Street <br /> S' c"on' California Lodi, California Manteca, California <br /> Tracy, Californial <br /> /-2M ,012 Revised <br /> W_2100 <br />