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�y� • r� r y � APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> a (complete in Duplicate) I <br /> P } bate Issued ._-..�-�-�---.• � <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work h in d cir;bed. <br /> This application is made in compliance with aunty Ordinance o. 549. <br /> 9 <br /> JOB ADDRESS AND LOCATIO _ ----- - ..--------- <br /> Owner's Name___A& t -`.....u-'Z ----------------------------------- - Phone------------------------------------- <br /> Address.... <br /> ---------------------------------- <br /> Address_... . .. �f <br /> Contractor's Name -( 7sy � "r't ------------------------------ = Phone <br /> Installation will serve: Residence JW Apartment House ❑ Commercial ❑ Trailer Court ❑� Motel <br /> ottkel�❑3Other ❑ <br /> Number of living units: ---I---- Number of bedrooms _ ". Number of baths ..�.___ Lot size ----../.___.-.�.---.__.�_____________________________ <br /> Water Supply: Public system ❑ Community system ❑ Private W Depth to Water Table &-J__ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay (yy <br /> Adobe E] Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes Od No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS.- <br /> (No <br /> PECIFICATIONS:(No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septi ank: Distance from nearest well-----------------Distance from foundation__._..--------_----Material------------------------------------------------- <br /> + ] No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity-----------`` --- <br /> © 1 V.-.---------Distance to nearest lot line... ............ <br /> Disposal Field: Distance from nearest well--- from foundation 3 J <br /> Number of lines------- p-- Length of each line------Y.,�f '_ .-_�____ <br /> Width of trench. ._ --------------------- <br /> Type of filter mater! - - -Depth of filter material.----- ------------Total length__..7--.%*------------------------------- <br /> of <br /> See age Pit: Distance to nearest well-__-/.---------Distant fro foun ation___.. ....... to nearest lot <br /> Number of pits /---------------Lining materiar�� Size: Diameter Depth -------------------- <br /> .i�--- <br /> nearest well-.-------__-----Distance from foundation----------------_..Lining material-------------------------------------- <br /> -------Distance from <br /> ❑ Size: Diameter--------------------------------------Depth-------------- -------------------------------------Liquid Capacity-------------------- gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- <br /> ❑ Distance to nearest lot lire----------------------------------------------- -------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):----------------- ------------------ ------------------------------•---•--•------------•-----------•--------------------------- <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 /> ordinances, Stat ws, and rules and regulations of he San Joaquin Local Health District. <br /> `: �rl _: _-' -------------------------------------------- (6°° br-Contractor} <br /> (Signed..---- - - -- -----,� <br /> sY� t +.�..--------------------(r le} <br /> (Plot plan, showing size of lot, location of system in relation to vUls, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY r� / <br /> APPLICATION ACCEPTED BY- ----------------------k--------------------- <br /> DATE----1..'' -- ----f--------------------------- <br /> REVIEWEDBY------------------------------------------------------------------------- ------------------------------------ DATE----------------------------------------------------------- <br /> BUILDING PERMIT ISSUED....----- ----- R --------------- DATE------------------------------------------------------------- <br /> Alterations and/or recon mendations----------------------- ----------------------------------------•---------•----------------------------------- <br /> ------------ <br /> -------------------- <br /> ------------ ----- <br /> ----------­------------------------------------------------------------------------------------------------------------•--------- <br /> --------------------------------------- --------------- _------•-------------------------------------------------------- <br /> —�-7 <br /> FINAL INSPECTION BY: . 0 -- <br /> ... _. 'l ! --------------------------- Date...-- ----------- <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 ; Revised W-2100 <br />