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_ y APPLICATION FOR SANITATION PERMIT Permit No. _ .... <br /> n (Complete in Duplicate) <br /> D " <br /> d" <br /> .,,�„• _ _ � _ , ate Issue <br /> � <br /> - - <br /> Applica+ion is hereby ade"to the San Joaquin Local Health Dis#riot for a pei=mit to construct and install the work her in scribed. <br /> This application is made in compliance with County Ordinance No. '549. ; <br /> f ... . �y <br /> JOB ADDRESS AND OCATION------------------ - -------- - lff f_._..I!f_____ _ <br /> Owner's Name------ ----------- ---_1 .:.f"- _-_-__-__----__-__-__ _____....._._..______,___.______...__.__.___._-"__p Phone--- �_r 3 ------- <br /> --Y - ,-� - x-r-r f- e-- - <br /> _,. . <br /> --- <br /> Address. •- - r.,. -- ---•--- <br /> r� „ o <br /> Contractors Name-----L�/�. --�..---/.�• -�-----r ----------- `---- -- - --•---• --•----•---------------------- Phone: 6 <br /> Installation will serve: Residence ❑ Apartment,House-❑ Commercial ❑ Trailer=Court 0 Motel E] Other ❑ <br /> Number of living units- :L__.': Number of bedrooms _1_" Number of baths _-�-r Lot�size __-____`----'57�--x---_ -��----__________________ <br /> Water Supply: "Public systemYCommunity system's Private ❑ Depth to"Wate�.Table _ 0_`ft. " <br /> Character of soil to a depth of 3 fe,tOS`and ❑ Gravel ❑ ~Sandy Loam ❑ Clay•Loani❑ ,Clay ❑ Adobe '( Hardpan ❑ <br /> Previous Application 1�ade:� Yes.❑ No New Construction: Yes No ❑ : <br /> TYPE 'OF INSTALLATION_ AND SPECIFICATIONS: <br /> [Na septic tank{or cesspool permit+ed.if public sewer is available within 200 feet.} , F <br /> eptic ank: Distance-from nearest well--------- ------Distance from foundation__^_-�_F_____----.Material-----__-_"_----._-:-_-----_---- ;_________. <br /> „ . of compartments-- .,---------- Size-------------------- Liquid depth Capacity--_------_---------- <br /> No. W <br /> Dispos I )=i Distance from nearest well ..-.._..---._;Distance from foundation __::.._.Distance to nearest lot line_________________ <br /> Number of.lines-- }-7-----� ,tLength of-each line �r r r F Width of trench - <br /> Type of filter material-____ '" Depth-of-filter material._ _-------Total length______________________ <br /> _ —.. - Urn. w.- '� ! -. ...1 �1 I <br /> Seepage Pit- Distance to nearest:well ft lDistanc from�fau dation .. �'�________.Distance to nearest lot line__-J__-__-_____ <br /> Number of pits- c Tg materiaSize. Diameter '��... Depth------�-Q�------------ --- <br /> __ I Lini 6 <br /> Cesspool: r Distance .from,neares# Well_______________'_.' ist nce from foundation_-______;__...'.....Lining material--__-_____------.__._..______________. <br /> ❑. Size: Diameter: ' = :_.... Depth_: ' ----------------------- --=----Liquid Capacity- •---•--------- - gals. <br /> Distance fromar�earest well ..Distance from nearest buildin <br /> Privy:` - -F ---------- --- _ g <br /> Distance'to nearest lot line_' ---_-.- <br /> Remodeling and/or repairing'(describe).--=------}'----------------------------:--- `--- ------1- -------...-•---------------- ----------------------- , .. - .----------------- <br /> ------------------- <br /> -------_ -- <br /> ------------------ {;---------------- -- --- ----=s{------ -_'--r - ---- a --_- ------F--------------------------------------------------------i--------- <br /> - - :� - "::meq;:-:-�,..,: -�:=a__ <br /> t ----------=--------•-•-------------- -�---------------•_-----•----=--------•---------•---•--•----•----- ---------------------------------' -- •., .-------•____----------------------------------------------- <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, Statejaws, and rules and .regulations of fhe'.San'Joaquin Local Health District .. <br /> (Signed <br /> k { � wT - nr ` <br /> er and/or Contractor) <br /> R <br /> ♦ 5 <br /> [Plot plan, showing size of lot, location of system in afibn to be,.placed`on reverse side].' <br /> K - 1"' FOF'R,D.EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------- ---------------!_1------- c -------------------------------- <br /> --- ------DATE----------- <br /> REVIEWED BY---------------------------------------.-: ------------------ <br /> - ----- —--- ---------=-----;. :�--- ---- ---------------------. DATE-------- -=--:-:------------------------------------------ <br /> .A7 <br /> BUILDING PERMIT ISSUED = -----­-------------��--------------------=. <br /> -=--------- DATA= = <br /> Ai+era+ions and/or.recommendations:____ <br /> to <br /> i <br /> v <br /> - ---- --- --- ---- <br /> �± � � � e -- <br /> •--------- •------------•----- -----------------•--------•--••---•-------------=--------•--- ------- •-•------------------ _ --- ------------------- ------ -- <br /> ----•-•----- --------------------- --- ------------ ------- <br /> Date__.`= r <br /> _ t <br /> FINAL INSPECTION'' By:.'____-_. .....--_____:_ <br /> _: — �,.� <br /> x <br /> - �-- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Streef 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ;. - Revised W-2100 <br />