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!!wN <br /> Permit No. <br /> APPLICATION—FOR SANITATION PERMIT ? y <br /> w [Complete in Duplicate] <br /> Date Issued _�_.�_9 <br /> plication 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 /> -------- -------- -- - --------------------------- <br /> --------------------------•--------------------------------------- <br /> JOB ADDRESS AND LOCATION_._._________-�_��- <br /> Owner's Name Phone <br /> Address_---_----------------------------------------- ------- ------ <br /> Contractor's Name-------------------------- L:� Phone <br /> Installation will serve: Residence pa ment House 0 Commercial E] Trailer Court E] Motel E] Other P -� <br /> CJS/ -___: ------- <br /> Water <br /> of living units: __'_: Number of bedrooins1_-__-_ Number of baths .:_1__ Lot size ------�"_-_---�-�__________ <br /> Water Supply: Public system ommunity system❑ Private ❑ Depth to Water Table -------- ft. <br /> L Character of soil to a depth of 3 feet:! Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe dpan ❑ <br /> I Previous Application Made: Yes ❑ No ew Construction: Yes -❑- <br /> { TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if pub`c sewer is,available within 200 feet. <br /> sly„ ce fr -----f -Material------/-L PC - i�""�_" <br /> Septic Tank: Distance from newest well ___��.-Dis§ante from f�o/undation__ � -------•- <br /> No. of compartments-_____ 4 _________Size-- __ /�- � Liquid depth_____ Capacity____ - - <br /> Dis o a{ Field: Distance from nearest wellh—OW— .Distance from foundation _ --- istance to nearest lot line___?,_ <br /> Number of lines____ _________ Length of each line------- F Width of trench._,J..__--------------------------- <br /> Type <br /> ---------------- <br /> De th' of filter material__--.1 Total length -.--_-__ ' <br /> Type of filter mateia {_ p .--- g <br /> Seepage Pit: Distance to nearest well_________ ___________Distance from foundation-----------.------- <br /> .Distance to nearest lot line---------------- --- <br /> Ti- Nu'mber of pits-__-_c'_-__'--- ----Lining matenal" � '_------Size: Diameter---------- ""` �Deptn- --- ------ -------- <br /> hge <br /> Cesspool: Distance from nearest weVk-----------------Di fs ancerfrom foundation_________ _______Lining material+k"----_---- ,_t--__*_--______ Y <br /> ❑ Size: Diameter------ s---- - Depth -------------- ---------------------Liquid Capacity----------------------------gals. <br /> yrs .{ <br /> r a__ -___________- from nearest building_____-_.____-______________ ._ <br /> Privy: Distance from nearest well----------------------------- -- --------- ' <br /> ❑ Distance to nearest Ilot line--------------------------------- --------------------------------------------------- ----------------• --------------------------------------- <br /> Remodeling and/or repairing (describe)=-------- ----------- ----------------•--•--------------•-------------------------------•-----------=- r ------------------------ <br /> I <br /> �• <br /> ......................I——-----------------------•-••--•-------------- --------------------------------------------------------------------------------------------------,�--------------------------------- <br /> ---------------------- •••-----`---...----------------_--- ---------•----------•-------------------------•-------------------------------------------------------;------------------------- <br /> I hereb certi# that I have re ared this a liratEon=incl that:t wwork will�be�done in accordance with�San J <br /> y-- tify have <br /> p p pp �i oaquin County <br /> ordinances, State laws, an rul s zn;!�;euIat;on5 ,ofJhe SanlJoacluin Local.:HealhDisfricf. <br /> [Ower and/or Contractor] <br /> ---------- -----------[Signed � Z. <br /> By:--------•---------------------------------------------- --------------------------_---------------------------.-------------------{Title)---------------------------•--9'-.------------- ------------- <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 /> APPLICATIONACCEPTED BY------------------------------- ---" -- ----•--- --------------------------------------- DATE...... �d� '`` ---------- <br /> REVIEWEDBY---------------------------------------------------------------------------------------------------- ---------------------- DATE----------------------------------------------------- <br /> PERMITISSUED---------------------------------------------- ------ DATE------------------------------------------------------------- <br /> Alfe'rafions and/or recommendations--------------------------------------------------:-------•--------------.------------•--------------------------------------------------------•-----•------- <br /> -------------------------------•--------------------------•---•----------------- ---------------------------------------------------------••---------- -----------•--- --- <br /> ----------------------------------------------•----•---•-------•-----•------------------------------------ ----------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:------ - -------------- Date---- ------- ------------------------------------ <br /> SAN <br /> --- ------------------------------SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stock+on, California Lodi, California Manteca, California Tracy, California <br /> 1 <br /> E5--9-2M 10-52 Revised W-2100 <br />