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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued _ 5 -�- <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 1 <br /> This application is made in compliance with County Ordinance No. 544. <br /> / �► T�.- , <br /> JOB ADDRESS AND LOCATION.(?- '---_- _ e -- - -------- -- p-•---------------"�-..._..-------- <br /> �a-A-e t/ � = <br /> Owners Name---------- ----- — '- '- -------------- - - ----:.- -- Phone <br /> E �-/ <br /> Address - - --- -•-----••---- --------------------------------------------------------- <br /> Contractor's <br /> ---------- ----- ------Contractor's Name--------•-•-----.----•----•-••-----`------------------------------------•----------------------------------•---------.....-------------------- Phone---•--------------------- <br /> Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _4__ Number of bedrooms _ _ Number of-baths -_�--- Lot size __�� _' __� �'S <br /> i h.. <br /> Water Supply: Public. system ❑ Community system ❑ Private [`Depth to Water Table <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam lay Loam ❑ Clay ❑ Adobe❑ Har 'span ❑ <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic,tank or cesspool permitted if-public sewer is available within 200 feet.) <br /> Septic Tan"""____'6istance from nearestwellr�J"".""�Distanc fr:o� found�fion ""�`�'Mate <br /> © � fi .- f� �.�__V __ _ <br /> ____________ p - _dNo. of compartments.____.-- Size--- --_Liquid depth.---�-.�__-.-__-.-C <br /> Disposal <br /> Field: Distance from nearest well.`,�.__S_...____Distance from foundation__ J_6___..__Distance to nearest lot-line-_-t�7.,_____- <br /> ® Number of lines--------A---:-------------------Length of each line------ Q_.-�� Width of trench.----- ----_-----------_.-.- <br /> Type of filter material__.5._ e0e-k-----Depth of filter material-----.__.........Total length-------- ----------------------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line--_-_.--__------_ <br /> ❑ Number of pits----------------------Lining material---------- Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation_-------------------Lining <br />�• ,.❑-....:-�»--��r -------------- <br /> Privy: <br /> m.aathearcia�.l__v,_.__,._�_.__-�---.-`_-_--_-.�._.:_--�_-._-_-_----•_g <br /> --�--f-s-.. <br /> Size•-0i me#e -•----------= <br /> Privy: <br /> . <br /> Distance from nearest well_ ------------------------------Distance from nearest building-------------.-------- --._-_--_--_---. <br /> ❑ Distance to nearest lot line--- --------------------I------- --------------------------•----------------------------------------------------------------------------- 1 <br /> Remodeling and/or repairing (describe):-------- ------------------------------------------------------------------•----- --..._-•------------------------ <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 /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed(------- -------- ;1Z "----------------------------------------- ----------------=--------(Owner.and/or Contractor) <br /> By-----­----------- re <br /> ---•----- --------------------------------------------------------------------------------------=------------(Title)--------- <br /> Title)--------- ------------- ---------------------------------------- <br /> (Plot pari, showing siz of lot, loca+ion of sys+em in lation fo yells building`-s`'a .,ccana eplac—id on-reverse=sidej: <br /> FORDERA,RTMENT USE ONLY <br /> All <br /> APPLICATION ACCEPTED BY-- .. --•---- ----- DATE-------- ------•------------- <br /> REVIEWEDBY------------------- -------------------------------------------------------------------------:-------------------------------- DATE-------- •--•-----_------ •- --- <br /> BUILDING PERMIT ISSUED------------------------------------------------- --------------------------------------------------- DATE-------------------------------- <br /> ------------------------- <br /> Alterationsand/or recommendations--------------- - ---- --------------------------------------------------------------------------------------------------------•----•-----------•-------- <br /> a ----------•---------•----------------- ----•---------------------- ----------------------•---------------------------•---------•••--••----•--__- ••-•--...•..----. ................------ <br />` ---------------------------------------------------- •-•------------------------------------------------------------------------------- ----------------------•--..--------------.----------------•-------•-----..----- <br /> FINAL INSPECTION BY:.---- � --' --- - ------------------------ ------- Date.-..- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Stremt 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> i <br /> ES-9-2M 145446 arw000 12.54 <br />