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A��_Yrx/`11 V ---- <br /> APPLICATION FOR SANITATION PERMIT Permit No. -- <br /> (Complete in Duplicate) <br /> -Date, Issued 244F <br /> kpplica <br /> A �;on is hereby made to the San Joaquin Local Health District for a permit to construct and install fhe'worl�herein described'. <br /> This application is made in compliance with County Ordinance No. 549. j —42-0- 3,2— <br /> JOB ADDRESS AND LOCATIONAO.1, _ ------57`---j6irl ot., A <br /> Owner's Name-------- .......e�_ -Wwxos-------------------------I---------------- ---------------------- Phonelle,4:77f' 92--- <br /> Address_....-----............ .....-1 0 F,_ ...........C�71)1-----------------------......---------------------------I-------- ............ <br /> Contractor's Name.--_/-) �?X <br /> _..,9,A. _ 'l-5 <br /> ..�_22W----------- ---------------------------------------------------------------------- Phone//e <br /> Installation will serve: Residence 04 Apartment House E] Commercial [] Trailer Court [] Motel [I Other E] <br /> Number of living units: _1.__-_ Number of bedrooms _t< Number of baths J----- Lot size ---4?e� )C_ ---/__5Z------------------------------- <br /> Water Supply: Public system $6 Community system 0 Private K Depth to Water Table--i(S—ft. <br /> Character of soil to a depth of 3 feet: Sand 0 Gravel I-] Sandy Loom El Clay Loam 0 Clay El Adobe DiT Hardpan [3 <br /> Previous Application Made: Yes [-] No g_ New Construction: Yes 0 No <br /> TYPE. OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest ---Distance from foundation-n-45-Z-7-----------Material--- <br /> --- --------------------------------- <br /> No. of compartments_!'______________ Liquid de" --------Capacity. (7 <br /> Disposal Field: Distance from nearest well__-_SV_ --Distance from foundation..-_-�r- ---------Distance to nearest lot linew,_,r------ <br /> 41 <br /> to Number of lines__4rvt&__r4J------------Length of each -----------Width oftrench______ ---------------- <br /> Type of filter Depth of filter maferi� :-______-__Total length----Sa <br /> ------------------ <br /> Seepage Pit: Distance to nearest well/�(-------------Distance from foundation-7 .#-------Distance to nearest lot lin <br /> e_/_4!_ ------ <br /> Number of pitsOW-----0)---Lining maferial__.0R.s_tX------Size: Diameter__-;5(8..............Depth--- ?C_`------------------ <br /> Cesspool: <br /> epth---,?C--------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-___--_____________.__________._____- OR, <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----_.___.___________________.________--- <br /> ❑ <br /> uilding----------------------------------------- <br /> F71 Distance to nearest lot.lin -------------- --------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe . ...... -------------------------------I---------------------------------I—--------I--------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------- <br /> ------------------­­--------------------------­1----------------------------------------------------------------------------------------------------------------------I----------------------------------------------- <br /> ---------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> I hereby certif I have prepared Phis application and that the work will be done in accordance with San Joaquin,County <br /> ordinances, State laws, a d rules and r laflons of the San Joaquin Local Health District. <br /> (Signed)------- --------- ------ • --.(-------------- ----------------------------------- ----------- -----(Owner pd/or Contractor] <br /> By:------------ --------_7.1 1-(------ ------------------_(Titl <br /> �4_Ir- (Title)-- _ t"Ze-- -- - ------------------------ <br /> (Plot plan, showing size of lot, location of system in re tion to wells, buildings, etc., can be pli Jon reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------- - - ------------------------------------------------------------- DATE ------------------- <br /> REVIEWED BY-------------------------------- --------- ------- ------- ---- ------------------------------------------------------- DATE------------- ------- <br /> 7""' <br /> DATE-------------•----- <br /> --- ------ -------- <br /> --------------------------------------------------------------------------- --- ----PERMIT ISSUED------------------------- --------- -- ----------- - ----------------------------- --------- DATE-------------------- <br /> Alterations and/or recommendations-----------------_. ------------_--_-. ---------- <br /> ---------------------------------------------------1­---------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ----------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------I-------------------------------------- -------------------------------- <br /> ------------------------------I-------------------------------------------------------------------------------------------------------------------------------- --------------------------- --------------------------------- <br /> FINAL INSPECTION -- --------------------------- Date------ ----- ------------------------------------ <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 /> ES-9-2M ; ' Revised W-2100 <br />