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APPLICATION FOR SANITATION PERMIT Permit No. __ _--.aj--- ___ <br /> (Complete in Duplicate) <br /> 1� 1 Date Issued <br /> Application is hereby made to the San Joaquingal Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with Codnfy Ordinance No. 549. <br /> � J <br /> ------------------------------ rJOB ADDRESS AN LO TION----- -------------------•- <br /> Owner's Name---=- 1 ----- ------ ---- -- ---------- --•-------------------- Phone <br /> e- 3..-7 <br /> Y� <br /> ----- <br /> - <br /> Address---------------- --------- --- ----____----------------------- ----------------------------------------------------_----•---------------- •----------- ---- <br /> Contractor's Name-------- ---------- -•-- -• , -------------• .'.. •-------- Phone-- r -- <br /> Installation will serve: Residence R---Apartment House ❑ Commercial•❑ Trailer Court ❑ Motel F] Other E]r r i <br /> Number of living units: _ __ Number of bedrooms -4___ Number of baths ____�. Lot size _u ____XI° _______________________________ <br /> Water Supoly: Publicsystem 9---C'ommunity system ❑ Private ❑ Depth to Water Table _loft. <br /> Character of soil to a depth of 3 feet:._Sand ❑ Gravel [] -Sandy-L-oam-E] A Clay-)=oar ❑ Clay ❑ AdobeHardpan ❑ <br /> Previous Application Made: Yes ❑ No 2 New Construction: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: Y. <br /> (No septic tank.or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank:y�� Distance from nearest well__'!'______________Distance from foundation_____________ Material________-----___--------------------------------- <br /> ❑�hy[�..e .No. of compartments--=--------=T------- -----Size---•-•-•---------------- ---Liquid depth-------------- -- ---tapacity----------------------- <br /> 41. <br /> Disposal Field: Distance from nearest welL_�'------------__Distance from foundation__:__________-:____-Distance to nearest lot line_________________ <br /> ❑ Number of lines-----------------r'--:----------'Length of each line------------------------------Width of french---------------------------------__ 1 <br /> Type of filter material--------- ---------------Depth of aria)--------:--------9--_--Total length----------------------------- —---.- lfV <br /> ' fir. d._- _Distance--.Distance to nearest lot dine_--�------ <br /> Seepage.Pit: Distance to nearest w II-------------- -_Dis nce fro fou da <br /> s Number of its "Linin mate .Size: -•x_--___-Depth___OO��_ --____-_ <br /> P g <br /> Cesspool: Distance from nearest well_:`_____-_______Distance rom oundation--------------------Lining material________-__-__-_____.______________. <br /> ❑ . , l Depth ----=------------------------- --Li uid Ca acit gals. <br /> Sze: Dia Fater- -------------------- �-- i� =. q p Y ----- <br /> Privy: Distance rom nearest yell_'________________ __._= _-.____----________ __Distance from nearest building---_------------------- <br /> ❑ - Distance to nearest lot'line°!'--------------------=---------'------------- ----------------•------ -------------------------- --------------------------------------- <br /> 11 T <br /> Remodelingand/or',-repairing (describe):-----------�ol-----------------------------•--•--------------------------•- ---------------------------------------•--------•----------------------------- <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, State ws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)--•- ---------- ----------------------- - --- ------------------------------------------------------------------------ ---- -- <br /> ---.lOwner and/or Contractor <br /> By:----------- ------ ---••-----------------------------=---------•-------------------------------------(Title)---- <br /> (Plot plan, showing ,size of lot, location of system in relation.to wells, buildings, etc., can be placed on reverse side). <br /> r FOR DEPARTMENT USE ONLY <br /> a 1j 3±. <br /> APPLICATION ACCEPTED BY DATE ----------------------------------------------------- <br /> REVIEWEDBY---------- ---------'---------------------=------------------- ----•-------------------- DATE--_ h---- <br /> BUILDINGPERMIT ISSUED---------------------------------o' -•-------------------------------------------------------------- DATE------:V----=-------------------------------------- <br /> 1 Alterations and/or recommendations:-------------- �- ---------------------- --------------••--------------------------------------------r-�------------------------------------------------- <br /> t <br /> ------------------•------------------•-----•-----------•--------------------------------------- ---•-__-----------­----------_- <br /> --------------------------------------------------•--------------- <br /> ---------------------------------•------------------ -------------•--------------------------------------- ----- <br /> > ' --------I'- ------- ------------------------•------------------------------------------------- <br /> -----------------------------•------------------------------------•------------- ------------------------------•------------- --------------------------• --------------------------•---------------------------------------- <br /> i - <br /> 6 3 <br /> FINAL INSPECTION BY:. ;- ----------- ------ Date-------pl -- ji <br /> f <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 /> E5-9-2M 10-52 Revised`W-2100 <br />