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• V <br /> ` 1 <br /> 5 `Y' APPLICATION FOR SANITATION PERMIT Permit No. <br /> a <br /> (Complete in Duplicate) ' <br /> Date Issued -__- <br /> Application is her by made to the San Joaquin Local Health District for a permit to construct and install the work herein described. #S# <br /> This application is made in compliance with County Ordinance No. 549. f <br /> JOB ADDRESS AND LOC TION ------Y----- - --------------------------------------------------------------------------------------------- <br /> Owner's Name----- --- -Y /C1 ---------•------- ---------------------------------------- ----- Phone---------------------------------- <br /> Address r l ------------- - * <br /> Contractor's Name-- -- -I-------��-- -�� ------------`-- --- ------------- Phone-- -F��--_.--'��-"-'_---- <br /> installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other. ❑ <br /> Number of living units: --L__ umber of bedrooms _ f?_. <br /> -/__ Number of baths .�---- Lot size __--_ 67 ------ _________________ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam ay Loam E] Clay ❑ Adobe ardpan E]Previous Application Made: Yes E] No New Construction: Yes No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ! <br /> (No septic tank or cesspool permitted if public/se is available within 200 feet.) <br /> Septic Ta Distance from nearest well - .----_ istance from foundation- _ _-_ ------ -- <br /> Distance <br /> of compartments 3 _ / --Liquid depth.- __-__Capacity-_.--j--�-----�-�--/--�--- --- ----------------- <br /> EVor <br /> Disposal FjM Distance from nearest well,0yd,14 -_ istance from foundation__ -___ Distance to nearest lot line <br /> y�_--_._____. <br /> r <br /> Number of lines__------------- Length of each line---- -----Width of trench_ <br /> t r/ <br /> Type of filter materials_ ! -_-Depth of filter materEal--,�_ ---_-___-_Total length______ ________________________ <br /> Seepage Pit: Distance to,nearest well--------------------_Distance from foundation--------------------Distance to nearest lot line----------------- d <br /> ❑ Number of pits----------------------Lining matsriai-----------------------Size: Diameter-----------------------Depth-------_------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material____----__-_---------------__---_____. <br /> ❑ ANY TSize: Diameter---- --.�_------ = ,.-----------Depth----=------------ -------==--=-----------`- Uqui'd CapacifY------------------------------gals. <br /> Privy: Distance from nearest well-------------------_------------------------------Distance from nearest building------------------------ --------------- <br /> El <br /> -------------❑ Distance to nearest lot line------- ------------- - •---------------- ------- -------------- --- - ---------- - -- <br /> Remodeling and/or repairing (describe)=------------- TT" ------ -----' ---- - <br /> I ----------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------- --------------------------------- <br /> -----------------------------------------------­---------I--------------------------------------------------------------------------------- -------------- <br /> -------------------------------- <br /> , <br /> _______________________________________________________________________________________________________________________________________________________________________________________________________----------------------- <br /> I <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 nd rules and regulations of:.the San Joaquin Loc Health District. <br /> Si ned ------ <br /> (Signed' <br /> _.--.----- {Owns`and/or ontractor� <br /> ( 9 • -- <br /> f <br /> -- --SY= t-�v " (Title <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 <br /> r APPLICATION ACCEPTED BY,-7-------------------------------------------------------------------------------------------- DATE_ <br /> -- ------------------------------------------------- <br /> AREVIEWED BY--------------------------- ` ------------------------------------------------------------------------------ DATE------ --------------------------------•---------•--- <br /> BUILDING PERMIT ISSUED-- rE� DATE V ------------------------------------------- <br /> Alteration? aqd/or recommendations------------------------------------------=------------------------------ <br /> a -----•----•----------------------------------•----------------------------------------------------------------------------------------------------- ------- -------------------------------------------•-------------------- <br /> M ----------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY-------------------- Date--------- --_ - <br /> -------•--------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak S+reef 132 Sycamore Street 814 North C Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5-9-2M 8-51 Revised W-2100 <br /> I , <br />