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APPLICATION FOR SANITATION PERMIT Permit No. <br /> r—---------- <br /> (Complete in Duplicate) Date Issued <br /> Application is hereby made to the San Joaquin Local Healfl-i'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 /> JOB ADDRESS AND LOCATION---0,64XA;tj&_j---)1-6 . .....------- ----4041 -------------------------- --- --------------- -------- <br /> .4r <br /> - -- - ------ - --------- <br /> Owner's Name---- ----- ------------- - ------------- --------------- ----------------------------------------- Phone. <br /> ill -.-- Phone-------------------------Address------------ -- ----------- <br /> ------------- <br /> Contractor's Name------------------------ z <br /> ,er --------------------------------------------------- phone----------------------------------- <br /> Installation will serve: ResidenceAp menf House F] Commercial [] Trailer Court E❑ <br /> .] Motel El Other E] - <br /> Number of living units: __j____ Number of bedrooms ----'), Number of baths _1--- Lot size -------IaO.--X---T.-0-------------------- <br /> Water Supply. Public system El Community system El PrivateK Depth to Water Tab], ff. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam E] Clay E] Adobe E] Hardpan,E] <br /> Previous Application Made: Yes E] No M. New Construction: Yes; No F-1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> ------------ <br /> Septic Tank: Distance from nearest we4------6_6kisfan;c�2frorn oundafion--- <br /> 1141—d.... ........ <br /> No. of compartments---------!7�<---------Si --A---N_Liqu'id clepth-------- --------- Capacify__lI7"__ <br /> Disposal Field: Distance from nearest well Distance from foundation----1_2.........Distance to nearest lot line------5--------- <br /> - ----- -------- Length of each M-.Mof trench-----.... <br /> K Number o' lines________ <br /> I Type of filter materiaI___,J1__P*it-kDepth. of filter material-----lj?A-------Total length___ _ -------------------- <br /> ? Seepage <br /> ength----- <br /> Seepage Pit: Distance to nearest welt-----------------------Distance from foundation_________--__.-_--_Distance to nearest lot line----------------- 0 <br /> El Number of pits.---------------------Lining material-----------------------Size: Diameter-----------------------Depth-,.......... ----------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.._--____._______.___-.___.-__--__ <br /> ❑ .,Size: <br /> aterial----------------------------------- <br /> -Size: Diameter----, .---------------------------.--.Depth------------- -------- <br /> - -------------;.�_-_ ----------Liquid,Capacity-._.----- _.____gals_ <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------. I <br /> ❑ <br /> Distance to nearest !of line---------------------------------------------------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe):------------------------------------- --------------------------•-------------------------------------------------------------------------- <br /> -- ------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------- <br /> ------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - <br /> ------------------------------------------------------------------------------I-------------------------------------­_------------------------------I-------------------------------------------------------------------- <br /> I hereby cerfify.fhat.l have prepared this application and that the work will be done in accordance with San Joaquin County 11? <br /> ordinances. State laws, and rules and regulations of the/San Joaquin Local Health District. <br /> ------LO1� <br /> -------------------------------------------------(Owner and/or Contractor) <br /> By:_ <br /> ------------------------------I ---------------•--------------------------------------•-----J -----------------------(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 /> APPLICATION ACCEPTED BY------------------------------ <br /> ------- ----------------------------- DATE------------------------------- <br /> REVIEWED BY---- ------------------------------- ('- ­_�_ <br /> BUILDING PERMIT ISSUED----------------------- ----------------------------- DATE------- ------- -------------- <br /> ----------- ----------------------------------------- DATE------------------------------------------ ---------------- <br /> Alterations <br /> ATE---------- <br /> Alterations "d/or recommendations:___ iw------------- ----- ------- --------------------- --­------------------- -------------- <br /> ------------------------------ --- ------------------------------------------- -----------------------------------------------­­­------------- <br /> ........................................ <br /> ------------------------------------------------------------------------ --------------------- -------------------------------------------- -------------------------------- <br /> ----------11-----------------------------------------------I--------------------------------- --------------------------------------------I ---------------------------------------------------------------------- <br /> ------------------------------------ ------- .................;-------------- --------Z----------------------------------------------------------------------- --------------------------------------------------------------- <br /> FINAL <br /> ------------------:----------------------------------------- <br /> FINAL INSPECTION BY:-.-'--,....... Date.-----------l -5 <br /> SAN <br /> afe_----------- <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 10-52 Revised W-2100 <br />