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•�� ^� APPLICATION FOR SANITATION _PEWIT_� ' Permit No. <br /> (Complete in Duplicate) j <br /> Date Issues!4� <br /> Application is horeby�made to the San Joaquin Local Health District for a permit to construct an install the work herein described. <br /> This app lication is made in compliance with County'.Ordinance No. 549. <br /> (' "fit <br /> JOB ADDRESS AND OCATION..._� __ <br /> Owner's Name---•- . ".._ . ✓� --------------r-----------....... ---------------- ----- Phone- <br /> Address------- <br /> hone Address-------------- <br /> Contractor's <br /> -----Contractor's Name- --------------- - ------ -- --'•------------------------ -------------------------- ----------------- Phone----- ------` = <br /> i <br /> Installation will serve: Residence` Apartment Huse p Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ,,,,�,., <br /> "' "` <br /> Number of living units: __�_ Number of b-edr®orris _ +NiSrb�e"rr'ofbaths, "L"o�tze -1a--------------------- - <br /> �_ . ., .....� ....:t_ .. . . _ ..,a _ .....,... <br /> Water Supply: Public system ❑ 'Co�unnity-sysfe ''El— Private Depth to Water Table .rs�___=ft. <br /> Character of soil.to.a depth of3 fee+: <br /> Sand'0= ravel E]—Sandy Loam —Clay Loa ay[ ,—Adobe❑':.Hardpan El <br /> Previous Application Mage- Yes [ NoNeGwConstructon: YeN� <br /> f s <br /> TYPE OF"IiVSTAL`'L'ATION AND SPECIFICATIONS: +' J <br /> Septic T o septic tank or cesspool permitted if public sewer is available within 240 feet.) <br /> anki"' Distance from nearest well_,J`�C>______Distance from foundation__ Q_--____-_.Mate <br /> I _4No 0of compartments_____-._ I,> Liquid de th_.� ------_._�Capaclfy4 ' 3 <br /> Size <br /> Disposak c eld:„ .,,Dist nce from nearest we!I__ Q-�--Distance-rf or m foundation__ _� Distance to nearest lot <br /> '[yMF�\-� NuAber of lines------- ---------------- -----Length of_each'line""`-----_,�' -----------Width of trench------: --�---,--------------- <br /> Type'or filter material-_ d`.__Depth"of filter material_._.lf-_________-Total length__------ �-Pte____._-_-----_------ <br /> Seepage Pit: Distance�ta-nearest.well-_"_�- Distance'from-foundation___-__-""_-:-Distance to nearest lot line________________- <br /> ❑ � Number of pits Lining material----------- <br /> ------------Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool- <br /> ------ '-----------------------Cesspool Distance from nearest well-----------------Distance from foundation_________________ <br /> Lining <br /> r Lining mate <br /> rial_-___-______Y___------____---------V <br /> El _ -------------------------- i ur apacity- --•--- ----------- <br /> ---------------------_---gas. <br /> Privy: ( s ance,fro nearest well-------------------------------------------------Distance from nearest building------------- -----. <br /> ❑ Distance to neares"tilot line--------------------------------- _ s+ <br /> 9k �. <br /> Remodelin and/or repairing Id scribe)': :n------- -------------------•-----...----------------------------------------------------------------•-- <br /> g <br /> - --- ------- ----•-----------------`----------------------------------------- R <br /> ---------------------------------------e <br /> -----------­------------------------------------------------ - i <br /> o ,, , <br /> ----------- ----------------- ---------------------------- --------------------------------------I­------------------I------------------------------------------- <br /> :�------------------------- <br /> ! hereby certify that I have prepared this application and'fhatf�e work will be done in accordance with San Joaquin County 4 <br /> ordinances State laws, and rules anpZgulations' of the San Joaquin Lata Health District. { <br /> F ,►i J. <br /> T <br /> (Signed).._ + ------ - ---------------------------------------------- ---------- ------------------------------------- (Owner and r Contractor) <br /> gY� 3 ...... --------------------------------------------------------- ' <br /> .� <br /> {Pio plan, 'showi g size of I ovation of system in relation to wells, buildings, etc., can be p ed on reverse sides). <br /> is ,e <br /> FOR DEPARTMENT USE ONLY ' l <br /> APPLICATION ACCEPTED BY ------�--- ----------- DATE l-� r <br /> `,,----.t' - ------ --------------------------- DATE----------- <br /> REVIEWED hY---------------•----- -=`=-------t. � �� -----•---•-------- -------- <br /> BUILDING FfERMIT ISSUED E""' _ r - "`= ?. s <br /> -- " _, ` <br /> Alterations is nd/or recommendations:-- --_- ----------------- - --i* ' �+ C!' _ E ,[ ' ! v •E,Q , <br /> ----. - ------ . - <br /> ------ <br /> .�. w <br /> FINAL INSPECTION BY:_.. --- _ = Date...... _ <br /> SAN JOA,QUIN 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 /> E5-9-2M 10-52 Revises! W-2100 <br />