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APPLICATION FOR SANITATION PERMIT Permit No. ____________ __ <br /> 414 <br /> f (Complete in Duplicate) <br /> 3R y Date Issued _?__. T <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 madein compliance with County Ordinance No. 549. <br /> JOBADDRESS AND LOCATION:--- ------ -----------E----------- _bmf---• --------- ------------------------------------------------------------------- <br /> Owner's Name---------- =------•-------- F -----•------------------------r------------------- - -----------I---------- Phone------------------------------------ <br /> Address-----=----=-------------:--------------------------- -------------------- -------------------_•...... ------------------------------------- <br /> Contractor's Name -------------- Phone <br /> Installation will serve: ResidenceAparfinent House ❑ Commercial ❑ Trailer Court ❑ Motel [❑ Other ❑ <br /> Number of living units: ------__ umber f bedrooms .'L"" Number of baths -------- Lot size ------61----------X 12-IM------------------- <br /> Water Supply: Public:system ❑ Community,systerii,❑.,,,,,P;rivateDepth to Water Table _#.- ft. <br /> Character of soil to a depth of 3 feet- i.Sand ❑ Gra''vel ❑° Sandyy oam ❑ Clay Loam E] Clay E] Ado6e Hardpan ❑ <br /> Previous Application Made: Yes,❑ NoVf New Construction: Yes/ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: '^ <br /> (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) <br /> .-sem.– �"� <br /> Septic Tank: Distance from nearest;well_____- -`�__-__Distance from foundation-----/0__-______.Material_____ 5=3l. �------------ <br /> -------- _ <br /> _ j) <br /> No: of com artments----------- -------"--Size---__-.,S __ "_ -- Liquid de th.. '"f.�-°-!-`__Ca acit �_5� �1]1• <br /> t s f or <br /> Disposal Field: Distance from nearest well__-__S0_ Distance from foundation______ :-:Distance.to nearest-lot line----S_________ <br /> f <br /> Number o{.lines--- ---------------- ---------""--Length of'each line------- of french---------9_q ---------------- �+ <br /> Type of filter material___._1.��A�-�___-Depth of filter material_._'►4E�______-_Total length__'_______1_ _�_ ------------------- <br /> Seepage <br /> `See a e Pit: Distance to nearest well-----------------_.Distance from foundation-------------------.Distance to nearest lot line------------ %14ElN imber of pits------------------- Lining material-�-r----y�'-_-----Size: Diameter----------------------.Depth-----------------------------_--- I <br /> Cesspool: Distance from. nearest well----'----=_-._.-Distance from foundation__.__.-___-______.Lining material__--___________________-_____. ___ <br /> ❑ Size: Diameter----------------------- -- ----Depth--------------- -------------------------------=----Liquid Capacity---------•-----------------gain <br /> ls. <br /> Privy:' Distance from nearest well-----------p`-------------------------------_-,.--Distance from nearest building_=______-___-________________._-_.._._"_. <br /> '•Distance•to•nearest lot.line-------------------------------------------------- "" . <br /> ❑ -n <br /> I <br /> Remodelingand/or repairing (describe)-------------------------------------------------------- ----------------------------------------• ------------------------------------------------------- <br /> -------------------------------------- <br /> -------------------• - <br /> -•--"---------- ----------------•----------------------------------•------ --------------------- --------------------------------------- <br /> --------------------•--------=------ ----- -----°----------•--------------------------------------------------------------=----------------------------------------------------------••------------------------------------- <br /> I hereby certify that ll-have prepared this applica+ion 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)_ zn!L _ --;- -- ---- __`------------------------------------------------------ -(Owner.and/or Contractor) <br /> By:-----���-_'- -•-- ---------------------­-------------------------- ------------------------•---------------r------------------(Tifle)------------------------------------•------------------------- <br /> (Plot plan, showing size of to+; location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- 6_�---------------------------- DATE--------------- <br /> REVIEWEDBY---------------------------------- --------=---------------------------------------------------------"I---------------------- DATE--------- -------- -------- <br /> BUILDINGPERMIT ISSUED--------------------------------------- ---- :_._. DATE------------------------------------------------------------- <br /> Alterations and/or recommendations------- ----------------- _ ------ - -• ------------------------ .-- --- a <br /> ----------------- <br /> . <br /> --------------- <br /> -------------------------------- ---------------------------------- A�----- <br /> .�. <br /> I I <br /> ----Ae i g' ,�> �-^�C ;Y .,.may: - ,... .:L <br /> �..._ ..� <br /> ________..------------------- <br /> ---------_-_____-_____4.________.___--_--------____`.-____-______________. _-_______-_______. ..___„---------------------------------------------------. <br /> s <br /> FINAL INSPECTION BY:.-: Date-----=-- --------------- ---- ." . <br />:f 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 /> t } <br /> � E5-9-2M Revised W-2100 <br />