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k��APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) n- . <br /> Date lssuede//��.�__�__�_3 <br /> ,i <br /> Application 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.wit County Ordinance No. 549. <br /> ' <br /> .JOB ADDRESS AND LO ATION--- -- ---------------- C""-- ----------zl-------- <br /> Owners Name---------- ,�1 ---------------------- one <br /> Address-------------------------- -----?`- -------- . A11^0_0---------------------- -?'` t- <br /> ame- <br /> Installation will serye:---Resid--------— ----------------------------------------------------------------=--- --------- Phone <br /> ence � Ap tment House ❑ .. Commercial.❑; ,•Trailer Court ❑.__ Motel / .Q er <br /> w Number of living units: Number of bedrooms Number of baths _ _ Lot sizei� _____ _______� _� — <br /> ,Ad <br /> Water Supply: Public system ❑ Community system ❑ ` Private' Depth to Water Tab[�'.____ f; <br /> Character of soil to a depth"of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made:' Yes ❑ No New Construction: Yes El No 1~, <br /> TYPE OF INSTALLATION AND SPECIRICATIONS: 'J <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> SeptiDistance from nearest well-----------------Distance from foundation-------------------_Material________________-_________________________- <br /> �jDis osal F 1d: No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity--.-------- •-------- <br /> p from nearest well---- eDistance from foundation__o O-__�_-Distance to nearest lot line-- "o , <br /> s <br /> , i <br /> enchumer. ones___________. Length ! ___.___. ______ <br /> Type offilter _ � <br /> material of filter material-_--- __.___Total length______' f_ ___ _:_ ' <br /> to nearest well_____________________Distance from foundation to nearest lot line------------------ <br /> Number <br /> _______-______. <br /> Seepage Pit: Distance - <br /> Number.of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h----------_-_--------------- -- <br /> Cesspool: Distance from nearest well_______________Distance from foundation-------------------_Lining material-------------------------------------- <br /> - <br /> ❑ Size: Diameter--------------------------------------Depth------------------------------------------- --------Liquid Capacity-------------- -gals. <br /> from nearest build•in --------_---------------------------------- <br /> ❑ Distance to nearest lot line-----------------------------------------------------------------------------------------------------_--------------------------------------- <br /> Remod ling and/or repairing (descrkbe�:- ll ---- --- -C -A--- - - <br /> l P34 -- E# •l�` '—' ----- -- •- ----------- <br /> ^! -----ems p -------- <br /> - . -1 <br /> - �' '' - <br /> � 2�+. v tt, - .• --- -.--- - -►-'------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that te work will be done in accordance with San Joaquin County <br /> ordinances, State laws, andiruies and.regulations of the San Joaquin Local Health District. <br /> l.e - <br /> .. `_ 1 -. ---- -----------------Owner and/oror Contractor) <br /> (Signed)-------- �- ------ <br /> PIK <br /> SYf = J -- ------------------------------------------(Title)-----------------;-------------------------------------------- <br /> - <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> l' FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED!BY----------------------------- �------ DATE---------------- -------------- <br /> -REVIEWED BY------- ----- --- ------------------------- <br /> _,B.UILDING_PERMIT.ISSUED- ----- - --- __ <br /> ----_---_---- �-�---`Ju -- ---- ---- DATE------ ------------------------------------------------ <br /> - <br /> ---- -- --- ----------------- <br /> _i-_ / t>�t � <br /> G * �Alteratonanor recommdI _____ _____ ______ <br /> _� � _________________..____-. <br /> � -------------------------- <br /> ------------------------------------------------ ------------------------------------------------------------------------------ ----------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-I—---------------------------------------- <br /> -------------------------------------------- <br /> FINAL INSPECTION BY------------------ ----- .____-- 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 8-51 Revised W-2100 <br />