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n <br /> APPLICATION FOR SANITATION PERMIT Permit No --f <br /> (Complete in Duplicate) -7 <br /> Date Issued <br /> - <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 complia�nc"ith County Ordinance No. 549.. 7 <br /> JK 440 <br /> JOB ADDRESS ANP`LO TIO ---941110 <br /> --- -------------- -- --- ------- -- - <br /> .. ....................I --------- <br /> le - -------- -- <br /> Owner's Name---- xZ---11____ -------- -------------- - -------------------------------------------------------------- ------------------The Phone--- <br /> Address.--------- --- - ----------- ------------;---------r-----------------------------------------------------------------------------------1------------------------ <br /> ----------------------------------- <br /> Contractors Name--- ­-•------------- ----- ----­------------------------------------------------------------------*------------------------------------ <br /> Phone <br /> F <br /> Installation will serve: Residence 'Apartment House E] Commercial E] Trailer Court [] Mofel,o Other ❑ <br /> Number of living units: ZNumber of bedrooms --- -,.Nu.mber of, <br /> baths --- Lot size ----------------- <br /> Wafer Supply: Public system El Community system El Privaf eDepth to Water Table ---- ft.. <br /> Character of soil to a depth of 3 feet: : Sand 0 Gravel E] Sandy Loa Clay Loam E] Clay E] Adobe �ardpan <br /> Previous Application Made: Yes [] No �7 New Construction: Yes ;�PNo El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS. <br /> (No septic tank or cesspool permitted if public available within 200 feet]. $c sewer Is av -_Mer'al <br /> Se ank: Distance from nearest weIk=_5,0,-Mt','Sf/a�nce fro fou a lion- ------------- ----- -------- % <br /> may <br /> No. of compartments--.----- 1z X1_ _-Liquid qep.tb __yam.-. Capacity----- <br /> S 1z <br /> istance to nearest lot lin ..... <br /> ance from fcundation-1-0- C­ <br /> DisposqYField; Distance from nearest wellt�?0�1�_ 'sf ---4, e <br /> ;? '- -_-Zi----------- <br /> r <br /> Number 1 iines ------- Length of each line-------- -- - ....Width of trench-- <br /> A_ epth of filter material------- _:-Total length------------------ --------------- <br /> Type of filter mater <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line____.-.--------- 1 <br /> ❑ <br /> ine----------------- <br /> El Number of pits------!---------------Lining material-----------------------Size: Diameter----------------------_Depth_..-----------------------------. <br /> Cesspool: <br /> epth--- ----------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation..... -------------Lining material-____----___-----._----__-__._-__-_. <br /> ❑ <br /> aterial-------------------------------------- <br /> ElSize: Diameter--------I----------I-------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals, <br /> Privy: Di❑ stance from near I est well.-c----------------------------------------------Distance from nearest buiiding------------------------------------------ <br /> Distanceto nearest lot ------------------------------------------------------------- ---------------------------------------------------------------------- <br /> Remoelini n gid Uc�i I <br /> and/or repai --------------------------------- --------------------------------•- <br /> y'- ---------------------------I-------------------------------------------------------- <br /> ---------------C-------- ---------------------- -------------------------------------- ------ ------------------------------------------ ---------- <br /> C1 --- . <br /> W-----------------------­----------------------------------------------------------------------_----------------------------------- <br /> --------------- --------------------------------I------------------------- <br /> ---------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------ <br /> 1 hereby certify that llh-aVe--Pre'�atred fl�7is placation and that the work will be done in accordance with San Joaquin County <br /> ordinances, sfa"wsl and ru an G ions of the San Joaquin Local Health District. <br /> --------(Owner and/or Contractor) <br /> ....... ... <br /> (Signed)... ..... ------ ----------------------------------------------------------------- <br /> ------- ---- ------ --- ------- ---- <br /> By------I------------------ ----------------- -- ------------------------------------------------------------(Tif le)------------------------------------------ ------------------- <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 /> APPLICATIONACCEPTED BY-------------- ---------------------------------------------------------------------------- DATE-------Z--- ----------- --------------------------- <br /> ------------- ------------ <br /> --- --- - ------------------------------------------------------------------- DATE- ____6/7 _1Z--------------------------- <br /> REVIEWED BY---------------------------- ---------- -=. <br /> PERMIT ISSUED-----------------== <br /> - - ----------------------------------------------------------- -------- DATE- -------- -------- ---------- <br /> Alterationsand/or recomniendations-_----------------------------- ------------------------­------------------------------­`------------------------------------------------------------------- <br /> I <br /> -------------------------------•---•----------------------------- -------------------------------I-----------------------------------I-------------------------------------------------- <br /> ----------------------------------------------------------------- - t --------•------------------------•---------------- .1 ---------------------------------------------------------------------------------I------------ <br /> ---------------------------•---------------- ----------------------------------------------------------------- --------------------------------------------------------­-•-•-------------------------------------------------- ----------------------------------------------------------------------------------------- ------------------------------------------------------------------------------ <br /> -TION BY------------------ Date-------------- <br /> /d <br /> FINALINSPECTION -------------- ------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> A 3 t-r�' 4- ' <br /> 130 South American Street , est Oak S-treet <br /> ' � 132 Sycamore Street 814 North "C" Street <br /> 00 W <br /> Stockton, California Lodi, California Manteca, California Tracy, California. <br /> ES-9-2M 10-52 Revised W-2100 <br />