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APPLICATION FOR SANITATION PEWIT IT Permit No. <br /> (Complete in Duplicate) <br /> - Date Issued .�__-��-5_`�-••� <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 application is made in compliance with County Ordinance No. 549. <br /> • A <br /> J ) <br /> JOB ADDRESS AND LOCATh• N-_------------------------Q �-�'' `" �u 1'` '� ---------------------------------------------------------- <br /> . ;`�- / Phone------------------------------------ <br /> ----- <br /> Name �/ ` -- - -------"-- 'f �`i �-------------------------- <br /> Address---------------•--------• ! C � P4 __ ----• ----- -- - <br /> r ,+�' <br /> Contractor's Name ---------- - 'te l=f "G�Rhone � 1 <br /> Installation will serve: Residence partment House ❑ Commercial El Trailer Court ❑ Motel [3y Other ❑ <br /> Number of living units: Number of bedrooms __ Number of baths __If__ Lot size ----__15_ _ _!1_ _� <br /> Water Supply: Public system Community system '❑ Private ❑ Depth to Water Table ________ ft. � <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Lodm E],-Clay Loam E] Clay Q Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No Uk�`New Construction: Yes EVN o ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> 1 t k <br /> G MateGi 1- `.�' s if <br /> Septic Ta}r k:' Distance from nearest well_CfV ------_Distance from ounda.tion___ ______________. <br /> �/ <br /> No. of compartments________-____.___ / _____Liquid depth___[____�__ __Capacity___s___6- <br /> ie ? , <br /> / -- - W <br /> Disposal Field: Distance from nearest well ` _ istance from foundation. d._________Distance to nearest lo�line_�` ________ O <br /> Number of lines___.____._________ _ _Length of each line____.�J__0____j__--__Width of french___ ___n---------------------- <br /> Type of filter mate" rial.s, _e_ _i--0epth of filter material__,/_�__�____.___Total length____1_2___��_______________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_________________ <br /> El Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------._ -_.Lining material------------------------------------- <br /> El❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well------------------------------------------------- from nearest building____________--____.•__---.-_____________- <br /> ❑ Distance to nearest lot lir e -------------------------------------------------- "fLl ------•-------------------------------------------- <br /> Remodeling and/or repairing (describe):----------------- �'��'�,{ {'' r-.-------_ r-'s-------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------•--•--------•--..._..----------------...------------•----------------•--------------•-----•-------------.-.. <br /> ------•-------------------------------------------------•- .------------.-------------------------- -----------------------------•---------------... --------------------------•----------------- <br /> hereby certify that l.have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regul9tions f the San Joaquin Local Health District. <br /> f <br /> (Signed -----------• --------------- .���,•- ••-. --t-���--=--- ` �� �' .---(Owns_wand/or Contractor) <br /> - ---------------(Title) �­_d•'�'d' ------------- <br /> By: <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 /> M <br /> I <br /> APPLICATION ACCEPTED BY --------------------------- DATE <br /> _ {,� a <br /> REVIEWEDBY----------------------------------- -------- ------ --------------------------- -------------------- ------ DATE------------------_±------- - <br /> IBUILDING PERMIT ISSUED---------------------------------------------------------------- ------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations- ------------------------------------------------------•--------------------------------------------------------•-----------------------------------------•-- <br /> -----•-----------------------------•----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------- ----------------------------------- <br /> -------------------------------- -- ------:----------------------------------------------------------------------------- --------------------- <br /> • <br /> FINAL INSPECTION BY:------ -------- - ----------------------------------- Date----o --"-" -J--V- - <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 8-51 Revised W-2100 <br />