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7 <br />1 - APPLICATION FOR SANITATION PERMIT Permit No. <br />(Complete in Duplicate) <br />` Date Issued <br />Applica*ion 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 -with e No. 549. County Ordinance zz�7w_... r rs 7 - od"� <br />JOB ADDRESS PD LOCATI __,--iF'_Gt1 _. --- -- -----------------• {�{I°.c'r��F+------------------------------------- <br />Owner`s Name------- ------ -- -------r�cc''" p Phone ----- �--- <br />Address <br />-- ���•: <br />Address-------------- -----_. ,aq--------------------- --------------------------------------------------- ------------------------------- <br />P -- - <br />Contractor's Name--------_V--�•r.,- y� Phone ._i_._�S0_ <br />Installation will serve: Residence E__19partment House ❑ Commercial ' ❑ Traile'Cou —10-ofe-f ther <br />Number of living units: ___ ____ Number of bedrooms ________ Number ofs _'". Lot size --- hrt------- ________________ <br />Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table�ft. <br />Character of oil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ CMj Adobe 9 --Hardpan ❑ <br />Previous Appl . ation ade: Yes ❑ No ew Construction : Yes to ❑ <br />TYPE OF IN ALLAT —A i "� Kee4fF - <br />(No se tic tank or cesspool permitted if public s wer is available within 2 feet.) <br />Septic Tank: Di ante from nearest well__ i__ _ .____ { <br />'Distance -from foundatio__:I:__t7___._____.MateriaL_��:__l� <br />N of compartments__ _ __ ____.__ Size_V *rm <br />rz � r. ____Ca acit �Q ------- <br />------------ <br />Disposal <br />____ <br />�L �a---•--------Li uid depth P Y <br />Disposal Field �. Di ante from n arest well -AA ----- __ D�'kanceoundation--�©_______-_--Distance to nearest lot line .---%®..__. <br />vN ber of lines _.___-------- Length of each line______-___�"P__.Width of french- ................... <br />Ty e of filter m terial _ _ "_ [leepth of filter material___ _.`........... Total length__ 1.Z_`�____-�''_ <br />` ante from f undSize: Di meter-. <br />� e to IQt lin'-��Q_•. <br />Seepage Pit: Di ante to near t vet .. - - Ll�s� 7 <br />N ber of pits-_ _�_ _ ----- ping aterial_____.. p <br />Cesspool: Di tante from n arest we�1____ ____.___ Distance from oundation__._ __.___.____.Lining material ______.____ _______________________. <br />Si . Diameter-- Depth ------------------ ------------------- ------------ Liquid Capacity gals. <br />Privy: Di tante from n crest well --- -t------------- ---------------------- f m nearest building_______________ ------------------------ <br />❑ Di tante to nearast:lot line ------------------- --------------------------- <br />Remodeling a d/or re Dairing (describe: ! :.e <br />4 <br />------------------ ------•-•------•--•----•-••----------- -------------------- ---------------------•----•-------------------------------------------••-•--••----------------- ----- <br />f <br />-------•-•----•------- ------------- -------- ------ --- - ---•------•-•---------•-•-----------•------- <br />----------------------- <br />------ <br />------------------ <br />--- - -- -- ---- —------------- ------------------------------------------------ <br />-- -------------------------------------•--- ------------------------­- -1----------------------------A� ------------------------------------------------------- <br />I herebyertif t at I have prepared this application andhat the woill be on in accordance with San Joaquin County <br />ordinances, laws and rules nd regulations of +he San oaqui Loca eal+h Distri t. <br />(Signed) ` t �r Contractor) �`.. <br />"-- <br />By------- ------------- --------------------- ------- --------- ----- ---- ----(Title)" ,lri� ---------------------- <br />(Plot plan, sh ing size of lot, location of syste n relation to wells ur i s, etc., c ni be placed on reveri side). <br />" FOR DEPARTMENT USE ONLY <br />APPLICATION'ACC-PED�BY.- ATE <br />�� --------------------------------------------------- <br />------ •----------------------�' - DATE-ra- ---------------------------------•-------------- <br />BUILDING PERMIT ISSUED DATE___-- <br />- _ <br />Altera+ions and/or re ommendations-------=-------------------------------------------------------------•-•--•-------- --•-----------------------------------------•-•---------------------------- <br />•----•--•-•------------------------ -•------•----•-•-•-------------------------------------------------------------------------------------••-•-•-•-----------------------------------------------------•---•---•---------- <br />---------------------- ------------- ------ --------------------•------------------------------------------------------------------------------------ ----------- -------------------------------------•---------•-------- <br />I <br />FINAL •INS ECTION BY-----------------�� ...,J-------------------- Date--------- f <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 />FS -9--2M I IRevised W2100 <br />