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APPLICATION 'FOR SANITATION PERMIT Permit No_ ______ <br /> (Complete in Duplicate) <br /> Date Issued ----�bh- <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 No. 549..: <br /> �r - ------------------------------------------------------------- <br /> JOB ADDRESS AND LOCATION.__._` ���d°�'�__'�_•_r_' __���-�`_________________ <br /> Owner's Name............ 4e _"v-'�x,4-- 1�---F_ ---_--------,-�-- ---------------------------------- ------------------ Phone_ _r :f- <br /> Address _ �.. - -------s — /f------------------------------------------- <br /> Contractor's <br /> -------------------------•---------------- <br /> Contractor's Name--- ----------P_'/d -Y'------------------------------------------- Phone <br /> Installation will serve: Residence,® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _/___ Number of bedrooms -4- Number of baths,�A'- Lot size 1 r -_ sem - ----------------------- <br /> Water Supply: Public'system ❑ "Community system ❑ Private ® Depth to Water Table j,1V ft. <br /> Character of soil to a depth`of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0 Hardpan ❑ <br /> Previous Application Made: Yes ❑> No 0 New Construction: Yes K No ❑ <br /> TYPE OF'INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank dr'cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well___V-_______Distance from foyndation___,.94f-___.___.Material '? /�-�----..__--_- <br /> h No, of compartments--- v Size_Z _X_tk__-_--.-..Liquid depth__-- ...___ . _Capacity__•-�_ __.� -- <br /> �� r f`- ---- <br /> Disposal Field: Distance from nearest wel4 -------Distance from foundation_____--_._.Distance to nearest lolline-_9__________ J <br /> Number of lines__--_--__---r�_.____-__________Length of each line------1"__��_____._.Width of trench-_,Z4- --------------------- <br /> Type of filter material_40v[/e_l-----Depth of filter material----/- -- ---------- length--�� ________________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_________________ <br /> [] Number of pits.--------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- <br /> I <br /> Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material__-_____-___-_----_________--_----._ <br /> ❑ Size: Diameter- '-- -------------------------------Depth-----------_-----------•----------------------------Liquid Capacity---------•-----_----------gals. <br /> Privy: Distance from nearest well--------_----------_-------------------------------Distance from nearest building____._____.__.___________•.__________._._. <br /> ❑ TM ' Distance to nearest lot line____________---------------------{ . <br /> Remodeling and/or repairing (describe):-----------------------------------------------------•------------•--•------------•---•--------I------------ ------ -----•-------- <br /> ------------------------------------------:------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------!--:--- <br /> -----------------------------•------- --------------- <br /> . <br /> F 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 <br /> "rules and regulations of the San Joaquin Local Health District. ` <br /> t / 2 `� �� <br /> (Signed) �1�---- ----- Owner ontracter <br /> B I . ._ <br /> • (Title)_ <br /> (Plot plan, showing size'of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ' .' - -------.-.--- -- = DATE ,j/71­ <br /> --------------------------- <br /> REVIEWED-BY----------------------------- ------------------------------ - DATE----------------••----------- <br /> ----- -----�------------�----------------------�-- - -•--- •--------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------ -------------- <br /> Alterationsand/or.recommendations:--------------------------------------------------....---------------------•------ -----------------------------------•--------------------------------------- <br /> ------------------------•----------------------- ---------------------------------------------------------= ...----•------------------------------------------------------------- ------------------------------------------ <br /> FINAL INSPECTION ------------------------------------- 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-9-2M Revised W-2100 <br />