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APPLICATION FOR SANITATION PERMIT Permit No. --- -_/�_ <br /> (Complete in Duplicate) ,..5� <br /> Date lssued,�l..-1............... <br /> Application is hereby made to the San Joaquin Local Health District for a permitg construc nd install the work herein described. <br /> This application is made in compliance with County Ordinances Ngo, 549, .yam <br /> JOB ADDRESS AND LOCATION__ .. ---- <br /> Lr_!....._I/Y.... <br /> Owner's Name---..-.-------- I. r <br /> f ........ �-•--.... . Phone-------------- <br /> ----`---- ----------- <br /> .0, <br /> Address ...... vContractor's Name__ Pho .",f <br /> ________ _ ---- <br /> Installation - <br /> _ <br /> - <br /> will serve: Residence [ p rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _._�_._ N er of bedrooms .,Z- Number of baths ___f_ Lot size ..AA�lf <br /> >�- -/._.+�'�+_ _..._.._.__. <br /> : Public s s+em` Communit system Private Depth to Water Table � t. <br /> Water Supply y y y ❑ ❑ P <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy roam ❑ lay Loam ❑ Clay ❑ Adobe Hardpan ❑ \ <br /> Previous Application Made: Yes ❑ .No ew Construction: Yes �to�❑ . <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: W <br /> (No septic tank or cesspool permifted if public sewer is available within 200 feet.) 0 <br /> Septic <br /> Ta, k: Distance from nearest well.................Distance from foundation____.___....__.__...Material_ _..-_-_ _..___.._.__.__...._.... ..___.. <br /> No. of compartments---- -----------"_--._...S'ze--------------------------------Liquid depth.-------------------------Caact <br /> p m neare,s we!i.44.K//Distance from foundation- --------•-..-.Distanco to nearest lot line._A$7---••- <br /> Dis ------------------ <br /> Disposal Fi D�srance from �I , <br /> Number of iines..... `^.!_ Length of each line .._.. .........Width of trench..... .,.. . . <br /> Type of filter mater:al. _ ._ r Depth of filter material._..1_ .ii _..._/.dotal length-----_�..�.__.__----Q--- <br /> Seepage Pit: —Distance to neares,t qwell.i✓O�r� Distance fr m�fou�-dation_ __.._..Dl' f ce.to nearest lot line___...__.___ <br /> ❑�� Number of pits----4% mss_. .._Lining material.__,-f�.rSize: Diameter___.,? ._.._....Depth_ -, �.............. <br /> Cesspool: Distance f om nearest well........... ..Distance from foundation................___.Lining material......................-. . <br /> ❑ Size: Diameter.....................................Depth..........................••--•-•-•-•---•__ - .-Liquid Capacity............................gals. <br /> Privy, Distance from nearest well .............:.__....._...___..._.._.._...Disfance from inearesf building----...................................... <br /> ❑ Distance to nearest lot line-------------------- ---`- ----------- <br /> Remodeling and/or repairing {describe):.--_-...-. ---_ __-- . !(----_-_--- <br /> • '-----. •-- --------- <br /> ........... ........ -------.... Ayl_ <br /> ._.t.__ __._ _ <br /> __..__JC____________ _ _ _ .__.. A <br /> ._1-. __________Fl--__ ___-_ / <br /> III- . <br /> .-.........._____.................---._._---:..___..------._.__.. .............._.__.._..__.... --- -----...-----------..---- ..__-._____-__---_-.____-_--_---.-_-__._._...._._.__..... _ . ..- <br /> 1-hereby certify that l have prepared this application and that the A will be done in accordance with San Joaquin County <br /> ordinances, State s,^an rules and regul ions of the San Joaquin cal Health District. <br /> (Sign d G r...."r . ... . _ .... (Owns d/or Cop actor]'. <br /> -- - . <br /> (Plot plan, soh wing sire of lot, location of system in relation to wells, buildings, etc., can-be placed on reverse side} <br /> s <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY....,............... ...•-----.._. .t . DATE.-•- --tt__ -,.�-S <br /> tviJ ------------ <br /> REVIEWEDBY--- -------------------_.........---•----...----•--•-•-•--.. -------.......____...-•--•-----•...__......_...---•--. DATE------•--- ---•--._....------ -- <br /> BUILDING•PERMIT ISSUED...............................----- ----------------------------------------------- ." - -•---- DATE..-------------------------------------------•-------.---•-- <br /> Alterafions and/or recommendations:_-._.-----------------------------------------------------"---•--------"-•-----••---------"------"-------------------.........__................ <br /> . <br /> ---•----------------------- •---•-•-----......._•-••-••---............. .............................................-­-----------­----------------------.................................... <br /> ...............................................................................................................•••. ..---•--•----•-----•----•----------------------------•-------------•-------------••-- <br /> r <br /> ----------....:............................. .-------------- .-.."...-.. ...-- ---.--."-.--•;.--:-..-----•-----.-•-.-.------------.-.-------_.--.---------------------------•----- ------------------------•---•- <br /> S <br /> � c E 3 <br /> FINAL INSPECTION BY:.........: . ..:.:..:-------.............1--•._...---------.. Date _ <br /> _ _......-•---�----�-....------------------------------------------------- <br /> SAN <br /> ------ ---------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Sha*+ 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 />