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APPLICATION FOR SANITATION PERMIT Permit No. 4`'--_-6. <br /> (Complete in Duplicate) <br /> Date Issued <br /> )Applica}ion 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 549. <br /> •f �. <br /> JOB ADDRESS AND LOCATION---- � T --- -------------dt ---------- --------- ` <br /> Owner's Name-------W---- - �- --------------------------------------------------------- ----------------------------------- Phone_-----.-•--- <br /> Address------.... -------- --------------------- ---------------------------------------------------------------------------- <br /> d <br /> Contractor's Name-------•-•-------------------------------- ------ / p-------------------- Phone.-�----- l-- .� <br /> - ------------------ <br /> Installation will serve: Residence Apartment blouse ❑ Commercial ❑ Trailer Court ElMotel Other ❑ i <br /> Number of living units: _/__ Number of bedrooms __4F'" Number of baths ---/_ Lot size __i p_._Y__ <br /> Water Supply: Public system 5( Community system ❑ ' Private ❑ Depth to Water Table`__41.A ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,® Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes 54 No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ' <br /> (No septic tank'or cesspool permitted if public sewer is availa6le`"within42004eet.)"'" t <br /> 4e.",711 nk: Distance from nearest well________________'Distance from foundation____._.____________:Material_-________._____________-_^{' Li uid de th.l <br /> .of compartments - -W-_'"�""�Sze-------------t --------- q P. Capacity_----------------- <br /> No. <br /> Dis0o ..3 Meld: Distance from nearest well................t,Distanee from foundation................... Distance to nearest lot line:_____.__________ <br /> Number of lines---------'------------- ?7----�eength of each line--------`-'--------------------Width of;trench----------------- - - <br /> Type of filter material----w__'--------------�De.pth of filter material.----------------`--:_-Total length--------------_--------------------------.� <br /> p r Distance from fo ndation__f*.'*_----_-.Distance to nearest lot line____'�_�__._ <br /> Number of its G-��- <br /> g Size: Diameter---)3-G---..-----_.Depth-----------'Z$---------------- <br /> Seepage Pit: Distance.to'nearest�ell-� Linin material_ _ _� r.___:___� <br /> r <br /> Cesspool: Distance:from nearest <br /> r well-----------------Distance <br /> -f-rom fou <br /> ndation___________.____._.Lining material------._-____--_____._________________- <br /> ❑ Size: Diameter ------------------- ;- Depth -= - -_1-ti--------------- --: ---_,-Liquid Ca acitY----------------------------9als. <br /> Privy: Distance frc m_nearest*weI1'r____-___--__..___"—__7_.-___'—`-----------Disfan'ce' <br /> ______--Distance'frorq".nearestbuilding-------------------------------_---------- <br /> ❑ ' -Distance to nearest lot1ire-------------__ ______ - •* .. <br /> 1 _-�-__�_._ �csv^ _.. ------------------------ <br /> ------______ <br /> Remodeling and/or repairing (describe______________ __ - -, - _� -------------r----- <br /> _� - � _ <br /> ----------- -- -------------------------- <br /> - <br /> c-------------j'---=---------------------------------------------------_-•------•-------------------------------------- --- -------------- --- <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, Stafp laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) ---------- -'^'---/ -------------- ----- --------------k---------------------(Owner and/or Contractor) <br /> • / j <br /> BY: _61-d (x ----- ---------------------------------------------------------------------(Title)----------------------------------------- ---- - -•------------ <br /> (Plot plan. showing size of lot, lot on of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> 'a <br /> FOR DEPARTMENT USE ONLY ' <br /> APPLICATIONACCEPTED BY------------ -- ---- --- - -------------------------------------------------------------- DATE------------------------------------- -------------------- <br /> REVIEWED BY------------------------------------ ---------------------------------------- ------------------------ DATE-_/ P - <br /> - -_------------------- <br /> - <br /> PERMIT ISSUED-------------•---r `` = - DATE---------------------------------------------- <br /> Alterations and/or recommendations:----------------------- <br /> ---•---•----------•--------••------------------------------------------------------------------ ---­--------------- :-•--------------•----------------------•--••---••------------------••-• ....-------------------------- <br /> - f <br /> ------------_----------------------------------------- ----- ------- - ------ ---- <br /> J <br /> F1NAL INSPECTION -BY:_ - __�. F_:_. - 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-4-2M ; Revised W-2100 <br />