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r „ APPLICATION FOR SANITATION PERMIT Permit No �57-e--�q--- <br /> (Complete in Duplicate) ��— <br /> Date Issued __ !d <br /> Appiica{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.wiith County.Ordinance.No 54 <br /> JOB ADDRESS A LOCATION__ _ ____ _ k._____ <br /> Owner's Name: - ----- <br /> OVO <br /> =----- - ---------- Phone------------------------------------ <br /> _ <br /> r <br /> Address--------- ..... e .. _ - -------------- ----- ----------- ---------------------' -- <br /> p <br /> Contractor's Name- 1 e- - ---- - - --- --- Ph ne s" J� <br /> - o � <br /> Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court E❑ Motel ❑ Other ❑ <br /> l I l -0' --_ <br /> Number'of living units: _d---__ Number of bedrooms ,>—Number of baths _�____ Lot size ------------------A-._!i__�_±�----_._._------------ <br /> Water Supply: Public system 'ommunity system_❑ Private [E]?Depth to Water Table ! ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy"Ld`arim ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> r <br /> Previous Application Made: Yes ❑ No E�- Iew Construction: Yes ❑ No [ '- <br /> TYPE OF INSTALLATION AND-SPECIFICATIONS:;,_ - _.., . .�.,,,_ ..�.�. . ,� , , <br /> (No septic tank or cesspool permitted ifpublicsewer is available within 200 feet.) <br /> Septic. Tank: Distance from nearest well-----------------Distance from foundation____________________Material ___________.___________..__________..__________- <br /> ..�j�/ No. of compartments--------------------- ----Size--------------------------------Liquid depth---------------- ---------Capacity----------------------- <br /> /Disposal Field: - Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line_______•___---•- <br /> Number of lines------`----------------------------Length of each line------------------------------Width of.trench----.---_-------------------------- <br /> Type sof filter material_________________________Depth of filter material-----------------------Total length-----------------------------------------_ <br /> Seepage Pit: Distance to nearest-well_/.k __Distance om fo ndation___-1�_ ___....D�stance to nearest lot line___.______.__ <br /> Number of pits__.___-_____-:-----Lining material__ �1+ __ Size: Diameter_-,._A__`.1-______..Depth_____Ali--Q_________________ 4 <br /> Cesspool: Distance from nearest well_____________ __Distance from foundation--------------§_-_.Lining material------------------------------------- (� <br /> ❑ Size: Diameter----------------- --------- - ------Depth-------------------------------- ------------ -.__Liquid Capacity---------------------------- <br /> Privy: . Distance from nearest well-----------------------------------------------------Distance from nearest building-------------------------------.---------. <br /> ❑ Distance to nearest lot line.'---------------------`---- -*_--------- <br /> Remodeling and/or repairing (describe):---Y-r- - � �� -__.. -------- ------•----•---•-•---•-------- <br /> _______________________________ ________ T A_________ _ _ __ _.__.___.. �------- <br /> -------------------- <br /> ------------------­----------- <br /> _ <br /> ____________________ ------------------------------------------------------------------------------------------------- <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 /> Joaquin Local Health District. <br /> � _ _ f <br /> ------ - <br /> ordinances, State laws, and rules and regulations o the an <br /> f�r �_______________ _ -caner.an. .or Contractor) <br /> _ <br /> '` ---- ----• ----- Ttle__-----�4. �'�"' <br /> :�---- . - 3 <br /> (Plot plan. showing'-size of lot, location of system in relation to wells, buildings, etc„ can be placed on reverse side). <br /> 1 , ' ti:' • FOR DEPARTMENT USE ONLY ' <br /> APPLICATIONeACCEPTED BY ---- --- ------- ---- --------------------------------------------------------- DATE----- -------------------------------- <br /> REVIEWED BY'" ---- ----------- ------ DATE - <br /> BUILDING PERMIT ISSUED ------- - DATE ------------ <br /> - ---- <br /> Alterations and/or recommendations---------------------- ---�i--r--------------------------------•----------------•--------------------•----•....... ..._._.._.._.. --••--. <br /> a� --= -- ---------•--••--------------- <br /> -------------•-- .................. <br /> t <br /> `�``� <br /> FINAL INSPECTION BY. bate =J '-= <br /> --------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130.South American Street 300 West Oat: 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 />