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APPLICATION FOR SANITATION PERMIT Permit No. ................... <br /> (Complete in Duplicates <br /> Date Issued <br /> 2-(2-- 1 R o z9 <br /> clication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describ d. <br /> This application is made in cpmpliance with County Ordinance No. 549. <br /> C71- <br /> JOB ADDRESS AND L CATION <br /> ____ <br /> Owner's Name.. ---•- - _.......... .++...........-...---•- <br /> ........ .... .........................................................I.......Phone.........--------- ................ <br /> Address.......................... •..11.'... ................. ............... ......---•-•---••..._... . ............_..__._........................................................................ <br /> Contractor's Name-•-•..............._.M. I "=� ..........................------..._...---------------------------------------___ ...._.__.._. - Phone.................................. <br /> Installation will serve: Residence ;K Apartment House ❑j Commercial ❑_ Trailer Court ❑ rMotel ❑ Other ❑ <br /> Number of living units: Number of bedrooms __Y- Number of baths ��.__. Lot size .__..!__ t'2_-0------------....... <br /> Water Supply: Public system [I Community system [I Private x Depth to Water Table .+_• 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 ❑ N60 New Construction: Yes N <br /> ® • o [ITYPE OF INSTALLATION AND SPECIFICATIONS: 11 , <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> ..fir <br /> Septic Tank: Disfance from nearest well-.-601------Distance from foundation.y ._-..Mater'BI .?...._.:--=--• ' <br /> No. of compartments...- e�i----•.---------.Size.. _ '-_XJ. ,.Liquid depth......3.�......___..Capacity--�-�.�J-�1-..-._.. <br /> Disposal Field: Distance from nearest weli'..TO......Distance from foundation.__. --.......Distance to nearest lot li ne.4.f�..._.... _N„ <br /> Number of lines....-... ....................... Length of each line------1__�.Q__ Width of trench..._�d...�................. (J <br /> Type of filter material.__._T Depth of filter material....... .. .......Total length_.... - ...................... <br /> Seepage Pit: Distance <br /> to rest well. -: Distance from foundation •Distance to nearest lot line------Numbeof pts ,-` _Lining material Size: _-- Dep{ _ _ r <br /> Cesspool: Distance from nearest well.................._Distance from foundation....................Lining material-_-._................................ <br /> ❑ Size: Diameter... ....................-••••--------•Depth....._.....-.-- --_--------••-------------.........Liquid Capacity;_ :•.._.y. gals. <br /> Privy: Distance from nearest well---_--_..................-.----___.............Distance from nearest building.......-_........__-___.____- <br /> ❑ Distance to nearest lot line----------------.----------................... •----------------------------•---••----------•-••-----•-•--------------------------•-------- <br /> Remodeling and/or repairing (describe):. G!U ...! GG..... ------------------------ <br /> 1 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 regulations of the San Joaquin Local Health District. <br /> (Signed}.. .-7+' ''t'lsri.............. <br /> ................. <br /> .._........ .--........--•----- ----------••-----•. ..._ <br /> .. --.._... -_-(Owner and/or Contractor) <br /> G� <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 /> FOR DEPARTMENT USE ONLY <br /> J <br /> APPLICATION ACCEPTED BY.................•-•-......._.......-••-•-. ------------....-- -.-.---------------------- <br /> .-. DATE. <br /> REVIEWED BY----------------------------------------•---•--_---- ................................. <br /> DATE <br /> BUILDING PERMIT ISSUED............................... •. .. > --•--..._...----•-------- DATE....-1 •-- - -- --------....... <br /> Alterations and/or recommendations:..............•-••• •- - ------------------------........--------------------------•--------•••-------------------•----------......._.. <br /> .....................................................................':................................................................---------...........................•-----------..............------................. <br /> ...............................................................................................................................................•....__ ..................................... .......................... <br /> FINAL INSPECTION BY:........ ............... Date....... c� -'.C�� ........................... <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 I0-52 Revised W-2100 <br />