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\ (l r APPLICATION FOR SANITATION PERMIT Permit No. .:__. <br /> 1 ) (Complete in Duplicate) 3 D�e Issued <br /> r <br /> 1 �y � <br /> Tglica�ion is hereby made to the San Joaquin Local Health District for a permit to construct and 'rt t work herein described. <br /> This application is made in compliance with County Ordina ce No. 549. <br /> JOB ADDRESS AND LOCATI N - - ------------ --------- ------------ - - <br /> ��: 3 <br /> • C'� --_�-- r Phone ,fir �o <br /> Owner's Name____ �^ •-f1-- 6 --------- <br /> -----------I�� ------ - ------- <br /> -�--. -- --- -- - --­------------- <br /> Address1p <br /> Contractor's Name SJ- .Kr ------------------------------------------•------------------ •-•------------ Phone :... <br /> Installation will serve: Residence [?""`Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___ _- Number of bedrooms _j__ Number of baths ___1___ Lot size ---- <br /> `lir__T___-t __L4.4___________________________ <br /> Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table <br /> Character of soil to a depth of.3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ff""Hardpan ❑ <br /> Previous Application Made: Yes [❑ No [New Construction: Yes 21<1 ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> �j�t <br /> Sept�,icyJT�nk: Distance from nearest well___'-1f--d_:.__Distance, from a oundation_____./�___.__.Material___`�________________________ _____________ <br /> YJ // -- <br /> No. of compartments-- __-__�-__ __._.___Size��__.X.. _ fv Liquid de th__-__ _____________Ca acct 00 <br /> Disposa ♦ ie4d: Distance from nearest well____!.___-.-_Distance from foundation---- ____-Distance to nearest lot Eine____��______ / <br /> Number of lines____-_.__-_, �ff Length of each line_____________�� Width of trench.__ _"___________________� <br /> Type of filter material_/L?_-- __-- _ ---Depth er•xrs al-------IoP- --Total length--------Pf �--------------------------` <br /> Seepag Pit: Distance to nearest �fell___1___,/__O------Dis nce from oun atioDis#a�a to nearest lot line__j_______. ___ <br /> Number of pits-____-_-l_____________Lining ma erial_C�_�__�'Size: Di meter__43_.___.__---Depth------ _______._____--_ <br /> Cesspool: Distance from nearest well_________________ 'stance from founda ' ----------.._.Lining material________.-____.____________________ <br /> ❑ Size: Diameter--------------------------------------Dep ---------------------------------------- Liquid Capacity gals. <br /> Privy: Distance from nearest well_______________________________--------------Distance from nearest building______--__._-___-__________.______-__-_-_. <br /> ❑ Distance to nearest lot line--------- -------------------------------------•------------------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe)=--- ----- --------------------------------------------------------=---------•---------------------------------------...._.__.------------...._.--------- <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 land rules and regulations of the San Joaquin Local Health District. <br /> --- --------- --- ---- -----------------------------------•--- ----- ------9w m and/or Contractor <br /> (Signed}---------------------------- ( / I <br /> ---•------ ----- • ---A ------------ {Title}---- <br /> By: '--------------- <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 /> APPLICATION ACCEPTED BY �J� DATE ------------- <br /> REVIEWED BY----- --------------------------------------------------------------------------- ---- <br /> ._ _ <br /> BUILDING, PERMIT ISSUED--------------------------------•------------------------------------------------------------------_ DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations:-------------------------------------------------- --------------------------------------------____...---------------------------------------..-----.------ <br /> -•---------------------------------------------------------------------------- --------------------------------------------------------- -------------------------•-----------------------•---------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------••------------------------------------------------•---------------•-----------------•--------------------- <br /> -----------------------------------•-------- ----------------------------------------------------------------------------------------------------------------------------------------------------- ------•---------•-------- <br /> .. <br /> FINAL INSPECTION BY---------------I�- � � ------------------------ Date..-------------- -------------------------------------------------------- <br /> I��------ ' ' -r <br /> " - <br /> I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 134 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy. California <br /> E5-4-2M Revised W-2100 <br />