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J- 2 s <br /> APPLICATION FOR SANITATION PERMIT Permit o. ------ <br /> (Complete in Duplicate) �6- <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. , <br /> This ap lication is made in compliance with County Ordinance No. 544. <br /> bw <br /> JOB ADDRESS AND LOCATION__,--.s"---�-e�Y�-- fi_sr --- ask ------ -5,--- --- cam ,--------- <br /> Owner's Name 'f4 ,- �,I �C_6� � � Phone <br /> ZE'tt.�a�d•�_. lgis--- a- <br /> Contractor's Name-------------------- r ' .----------------- Phone--- - D --------- <br /> Installation will serve: Residence' Apartment House El Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _ Number of bedrooms _ _ Number of baths __1-Lot size P--- -�_____` 4' /D <br /> Water Supply: Public system , Community system ❑ Private ❑ Depth to Water Tablet 3 4)ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe(�, Hardpan ❑ <br /> Previous Application Mader Yes ❑ NoX. New Construction: Yes ❑ No ❑ <br /> ff <br />} TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> e fic ja.k: Distance from nearest well_________________Distance from foundation <br /> dation Material - . <br /> No. of compartments Size Liquid depth Q Capacity---------------------- <br /> h <br /> ' pos�l Feld: Distance from nearest well________________,Distance from foundation--------------------Distance to nearest lot line----------------- <br /> Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length----.---..-------------------------------- <br /> 'Seepage Pit: Distance to nearest well__!`i 0_jV,____Distanfro fo ndation__zZ._.__-___.Distaicp to nearest lot line- -�_ -_-_ t A <br /> Number of pits-____---------Lining materia„_ Size: Diameter__ - -------Dept h---'"__ ---------------- vS <br /> Cesspool: Distance from nearest well-----------------Distance from foundation_ _ ____________lining material- --_-___________ _ <br /> r ❑..: - Size: Diameter---------------------------------------Depth-------------- - ---------------------------------I <br /> -------- -- - -- -- ----- LL q id Capacity- -------------------------gals. i <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------- ------. ” <br /> ❑ Distance fo nearest lot line-•--------------------------------------------------------------•----------------------------------------------------------------------------- W <br /> Remodelin end/or repairing (de be) - J � --_- --- - Y......._. <br /> rama ��, -----------------�`--------------- =--------------------- -------- --- ------ ------------- -------------- <br /> -------------------------------------- <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 /> ordinances, State laws, and ri les and regulations of �e San Joaquin Local Health District. <br /> I <br /> (Signed) •_-_i�+_____ <br /> ( 9 )....... - •----------- ----------- --------------.------------------------- { <br /> " - ao► Contractor <br /> ------- <br /> By..... =------------ -�------------------------------------------------------------------------(Title)- ���17�-� �------------------------- <br /> (Plot plan, sho ing size of lot, location of(system in relation to wells, buildings, etc.,tcan be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> r APPLICATION ACCEPTED BY-- ---•-------:----------------------------------------------------------------- ------ DATES.. <br /> REVIEWED BY ------------------ DATE--- <br /> BUILDING PERMIT ISSUED---------------------------------------------------------------------------------= ------ DATE <br /> Alterations and/or recommendations-------------- -------- ------------------------ ----------------------------------------------------------- - <br /> --------------------------------------------------------------------------------- ---------- --------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------ <br /> FINAL INSPECTION BY: ---------------------- Da+e..-_-_--- _- � `----- <br /> C <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f <br /> 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 #g <br />