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APPLICATION FOR SANITATION PERMIT Permit No. .. <br /> (Complete in Duplicate) Date Issued A1111-6-3 <br /> Application is he by 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 County Ordinance No. 549. <br /> JOB ADDRESS AND LO ATIO -----1. ------ <br /> Owner's Name--------------------- I <br /> - -- ------- - - - -- ------------------ ------------------- Phone------------------------------------ <br /> Address--------------------------- ....... :­ 4 <br /> ----------- ----------- -------------------------------------------------------------------------------- <br /> Contractor's Name.-. --- -------0 s, lor / 11 <br /> d .0- ---7 --_ ------------ Phone_ <br /> Installation will serve: Residence artmerif House ❑ Commercial ❑ Trailer Court [] Motel L] Other El <br /> Number of living units: umber of bedrooms Number of bai•hs I--- Lot'size <br /> Water Supply: Public- system C Private E] Depth to Water table ft. <br /> E'❑ <br /> n <br /> Community <br /> 'y 0"n <br /> 'u <br /> Character of soil to a depth of 3 feet- Sand Gravel E] -Sandy Loam 0=�Loam ❑ Clay E] Adobe Hardpan ❑ <br /> y <br /> Previous Application Made: Yes E], Na Sand <br /> Construction: Yes [A-1Nb E] LA <br /> . I f <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ' <br /> (No s tic tank or cesspool permitted if pu606 se er is available within 200 feet.) s. <br /> n ---- -------- <br /> Se fi T Distance from nearest wellAW44AXisfance from founclafio ---------Material- <br /> Pd/ NO. of compartments -------------Siz Liquid depth---1Xj_/9-------_-_Ca acit F4r,<. ---- <br /> Disposal <br /> Distance from nearest weIWa_44/d1/Disfan'c'e from founclaf ion_/I!'_ .. <br /> �. ....Distance to nearest lot)ne---40__/I--- <br /> Number o-i lines-_X4a ---- -----Length of each line------�?&�----- - __._.Width of trench- <br /> Type of filter mate i�� _.V <br /> -ZA.--Depfh of filter material-----/_.--__.__:__._------------Total length------ <br /> Seepage'Pif: Distance to nearesti wel)-1--- ----------------Distance from foundation---- ----------------Distance to nearest lot line <br /> El Number of pits.-----ILining materiahL�___.---------- <br /> i -------Size: Diameter------------------ ----Deptn------ -------------------------- <br /> -------------Lining <br /> ---------- 4 <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------!._.Lining material-_----._._____-____.____._-______--.El Size: Diameter. - ---------------------------------------------;-:--Liquid Liquid Capacity------------ ---------------gals. <br /> ----- - ------------ <br /> Privy: Distance from nearest well------------ ----------------------------------.-Distance from 6aresf building--------------------------------------- <br /> ❑ Distance to nearestlot line------------------------- <br /> ------ I line----------------------------------------------------- <br /> -------I--- <br /> --- <br /> --------------------------------------------- <br /> Remodeling and/or repairing (describe):-- - --- ---- --- --- 5 ----�9------------ <br /> ------- <br /> ----- <br /> -------------------- <br /> --------------------------- <br /> - <br /> - A - ---- <br /> -----------------•------------------------ <br /> --------- ---------------------•-------------^------.._-...------------ - -------------- ------------------ ---------------------------------- - ------------------ <br /> -- <br /> I hereby certify that I have prepared this application and th'at the work will be done.in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Jbiaquin.Local Health Disfrici.4 <br /> (Signed).... <br /> By: Contractor) <br /> ­------------ ---- - -----Y%A­-fZ�--------------------------------------------------------------------(Title)---- --------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can 66 placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY-j- ---------------- ------- ----------------------------------------------------------- DATE------------------------ -------------------------- <br /> REVIEWED BY--------------------------------- <br /> --- ------------- - -------------------------------------------------------------------- DATE__ ---- ------- <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE--- <br /> Alterations and/or recommendations- ------------- ----------------------------------------- kp <br /> ------------- ---------------- <br /> --------------—--------- ------- --------------------------------------------------- <br /> 7 A ------- <br /> j4x � <br /> ---------------------------------- -------- <br /> ------------I------- ---- -1- ------------------------------------- <br /> _ke-------- _k ------ --- ----------------- --------------- <br /> ------------------------I---------- ----------------------- <br /> - ---------- ---------- - -------------------------- ---------------------------------------- <br /> --------------------------------------------------- ------------ -- --------------------- ------­---------------------------------- - ------------ --------------------------------------- <br /> FINAL INSPECTION BY:__---__ <br /> --- ------------ Date--------- ` , <br /> SAN <br /> at-----------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 10-52 Revised W-2100 <br />