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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Data Issued <br /> �J_�s=�__. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and installihe work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> -- --------- <br /> JOB ADDRESS AND L CATO ------ - ------------- <br /> ---------------------------------------------------- <br /> 2--&3 —12,o—o6 <br /> ---------------------------- -------------------------------------------- Phone------Owner's Name---------- F4 <br /> Address........--------------------------- ---- .. ......6j4t_-S............ -------------------------------------------------------------------------------------------------------- <br /> Contractor's Name----------------------------------------------- ------------------- ------------------------ --------------------------___--- -------- Phone----------------------------------- <br /> Installation will serve: Residence [R Apartment House E] Commercial 0 Trailer Court 0 Motel 0 Other El <br /> Number of living units: Number of bedrooms _3___ Number of baths .1--- Lot size _____________________________.______________________.__._ <br /> Water Supply: Public system El Community system E] Private Depth to Wafer Table 7-kft. <br /> Character of soil to a depth of 3 feet: :Sand F] Gravel F1 Sandy Loam D?0'00ay Loam 0 Clay E-] Adobe[-] Hardpan ❑ <br /> Previous Application Made:' Yes [-] No �New Construction: Yes file"No El <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 well---- -------Distance, fro fou rgd tion__._-!A---------M�ajffrial-----1A and-4—------ ------ <br /> fX ----X-6----Liquid dep.th--------------_---------C <br /> No. of cornpartments------- ----Size_ apacity---- ------ <br /> e 20*'PA-�46isfance from foundation,---- ----Distance to nearest lot line--- Z, <br /> Disposal Field: D;stance from nearest well SA 1 20--'- -------------- <br /> .Number of lines__________;2_1------".- ----Length of each -------Width of --------------- <br /> Type OT filter material - -- ---- -Depth of filter material----- Total length-----------1__&--------------------------- <br /> Seepage Pit: Distance to nearest well____________________ Distance from foundation--------------------Distante to nearest lot line__.______________ <br /> ❑ <br /> ine----------------- <br /> r_1 Number of pits----------------------Lining material-----------------------Size: Diameter------------------ ----Depth-------------- ----------------- <br /> Cessp ool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_______.-_____._____.____._.__-_--_. <br /> 0 Size: Diameter------------------ ------- -----------Depth--------------------------------------------- -----Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-----------------------------------_---------- -Distance from nearest building_--_--------_-----------_____--_---.-----.j <br /> ❑ <br /> uilding------- ---------------------- -- ------ <br /> F-1 Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------r----------------r---- - - <br /> -ND <br /> Remodelin"g and/or repairing [describe)-------------------------- ----------- ---------------------------------------------------------- ------------------------------------------------------ <br /> ----------------------------------------------------1----------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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 rules and regul tions of the San Joaquin Local Health District. <br /> (Signed)- ---------------T---------------------------- ---------------------------------------------------------------------------(Owner 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 /> PR -KRENT U E ONLY <br /> APPLICATION ACCEPTED BY <br /> DATE__._ 4/1; --------------------- <br /> ------ --- ---- - --------- <br /> REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE. - ------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------------------------------------- <br /> Alterationsand/or recommendations:------------------------------Z----------Z----------------- ----------__--------------------------------------------------------__----------------------- <br /> ----------------------------------------------------------------•------.-..-------------------- ----------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------I------------------------------- ---------------------------------------------------- <br /> ----------------------------------------------------------------------------------------- -------------- ---------------------------------------- -------7----------------------------------------------- ------------------ <br /> ------------------------------------------- ---------------------- --- -- ------ ------------------------------------------- -- -------------------------------------- - ------------- ---------------------------------- <br /> FINAL INSPECTION BY------ - ---------------------------------- 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 J0-52 Revised W-2100 Cbo <br />