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APPLICATION FOR SANITATION PERMIT Permit No. Jll ----- <br /> (Complete in Duplicate) <br /> Date Issued <br /> Applica4-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the rk here <br /> This application is made in compliano yfh Cou Dr encqyNo 549 in described. <br /> V 11-M 4 . ;�� or <br /> r t­�- <br /> JOB ADDRESSI"D jL TIO ;) 2 t-V� a,,o,-* <br /> --- - ------------ <br /> f. <br /> ------ -------- ----------- Pho`n-AUZ� <br /> ------------------ -------------------- ------ <br /> Owner's Na ---- I- <br /> arm­ A, e <br /> - --------- <br /> L <br /> -- - ----------- ---------------------------------------------------- ----------------- <br /> Et�-- ----------------- <br /> Address------ --- ----------- <br /> -4-s --------- ---- -------- - <br /> Confractor's Name----- ---- --- ----- ---- ------------------------------------------------------------------------------------------------------11---- Phone--------•--------- <br /> Installation will serve: Residence- Apartment House El _Commercial E] Trailer Court [] Mote 0 Other <br /> Number of living units: j--- Number of bedrooms -;?V Number Tf baths -1---- Lot size ---- <br /> -------------------------- <br /> Wafer Supply: 'Public system [] Community system El Private <br /> * <br /> epfh to Water Table -------- ff. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel F] Sandy L Clay.Loam o Clay [] Adobe [:] HardpanE]. <br /> Previous Application Made: Yes [] No New Construction: Yes o;"NoFl <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if bli gv i available within 200 feet".) <br /> Distance from ni ,,Ful I T sewer avai a e <br /> Se tic earest we P.-'*�-- -isfariQe f[Qrf fo 4afion--10---------Mate ill----- <br /> -----------------------------I --------- <br /> No. of compartments__---------- 2�S-,,e-AP>�-&KX------Liquid 4epfh--- -ILT------------Capacity----C (0. <br /> Dis Field: Distance from nearest wel .... ndation- <br /> 0 'Stance from 4 1-03��Disfance to nearest lo ine - ---------- <br /> Number of lines-­ I— <br /> P ---------J-ength of each-11ne--------- Width of trench._______ _ <br /> t-------- <br /> 0 -------- 0--- <br /> Type 7 filter materiast#Aft'c7pth of filZr-'M' aterial----------LY- .-Total length---------------/-- - ---------- <br /> I <br /> Seepage P;f: Distance to nearest well- --------------------Distance from foundation-------------------LDistance to nearest lot line-____._____----_- <br /> 171 Number of pits----------------------Lining material---_____-___-----'----Size: Diameter-----------------------Depth------------------------------_-- -- <br /> Cesspool: Distance from nearest well----------------Distance from foundation_._._._._-_-._.--_Lining Lining material------------------------- <br /> ------------ <br /> ElSize: Diameter------ -------------- ----------------Depth_---------------- ------------------ -------------- <br /> ----------­Liquid Capacity----------------------------gals. <br /> 1 -rom neaf-e&i�,building,-------- ----------- - <br /> Privy: Distance from nearest'- -- ------------------------- - -- <br /> ------- --D'1sla n ce!f <br /> 0 Distance to nearest lot lire------------------------------------------- <br /> Remodevrg an /or repairing 1pc�ibe),­�--------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------- <br /> .. . . ...... . - --- ----------- ---------------------------------------------------------------r------------------------------------------------------------------------------------ <br /> 4 <br /> --------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------­­----------------------------- <br /> 6 <br /> -----------------------------------------------------------------------i------------------------------------------------------------------I--------------------------------------------------------------------------------- <br /> I h eb certify that I have prepar d�his application and that the work will be done in accordance with San Joaquin County <br /> I application <br /> c,r I r __�? S, <br /> ordinances. Sta e laws, ano rules and&rula "ons of the San Joaquin Local Health District. <br /> (Signed)----- ... --------------------------- <br /> ;--- ---- -------------------- ----------------------- --------------- -------------------------­------------------(Owner and/or Contractor) <br /> By:---------------------------------------------------------------------------­-------------------------------------------- ------ -(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 /> BY-V-------- ----- --------------­------------------- --------------------I------------------- DATE-JP—�,------------------------------------------------------------------------------------- <br /> - <br /> REVIEWED BY-------------------------------- . ------------ DATE-- - ------- ------ <br /> BUILDING PERMIT ISSUED- <br /> --- - - ----------------------------------------------------------• DATE------- yy- <br /> �'F" - - - <br /> Alterations <br /> ATE-------- <br /> Alterations and/or recommendations:------------------ -------------------------------------------------------------------------------------------------- <br /> - ---------- ---------------------------------------------- --------------------------------------------------------------------------------------- ------------------------- <br /> -------­-----------...... <br /> -------------------------------------------------- ---•----------------------------------------------------------------------------------------------------------------------------- ------------------------•-------------- <br /> -- <br /> --------------------------------- ------------------------------------- -------------------- ------------------------------------------------------------------------------- ----------------------------------------------- <br /> ---------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------- ------------------• <br /> FINAL INSPECTION <br /> BY:.......... ......lt�----------------------------I----- Date........ <br /> ------------------------------ ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" S <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M , . Revised W-2100 <br />