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MIT Permit No. .. ___-.�0-- - <br /> APPLICATION FOR SANITATION PER <br /> t (Complete in Duplicate) <br /> Date Issue l(�&?/�=3 <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 with County Ordinance No. 549. <br /> JOBADDRESS AND LOCATION------- ------------------------------------------------------------------------------------- - ---- <br /> Owner's Name t ---------- - - ---------------------------------- phone <br /> } Address_---------------------- -------------------­-_-._a- `_e------------------------------------------- ------ ----------------------------------------.....-.------------------•-----,------- <br /> Contractor's Name--- -------------------------- a;? �Z,c�c ;------ —------------------------------- <br /> Phone.-_�� Q <br /> Installation will serve: Residence ElApartment House E] Commercial Trailer Court E] Motel ❑ Other C] <br /> Number of living units: '_ Number of bedrooms -- __ Number of baths —5--- Lot size __ _ _ -- - .-.----------------- <br /> Water Supply: Public system J?L Community system ❑ Private ❑ Depth to Water Table + ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe R_ Hardpan ❑ <br /> Previous Application Made: Yesk 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 /> tic Ta k: Distance from nearest well-----------------Distance from foundation--------------------Material---------------------------------------------_-_-. <br /> No. of compartments-------------------- ---Size--------------------------------Liquid de th------------------- ---Capacity <br /> osal ii Distance from nearest well------------- ----------Distance from foundation ":_-_--_-.--Distance to nearest lot line_-_--___-_----_-. <br /> Number of lines-----------------------------------Length of each line-----------------------------Width of trench---------------------- - - -------`nVl <br /> Type of filter:materia------------------------- of filter material--_.-_--.--_____.-_-Total length------------------------------------------ <br /> Seepage Pitt - Distance to nearest well-NONE-__-__Distance fronj foundation-11-_'o__--___.Distance to nearest lot line_-1__OP------ Vo <br /> X dj Number of pits--I----_-------------Lining materia l_4fx_-_. d5.-Size: Diameter_._��.---Depth----&.Q__'_-_.._________- <br /> A I <br /> Cesspoo : Distance from nearest well-----------------Distance from foundation-.-._------.._-_-._.Lining material_-.__..._______.__.____._.__.____._. <br /> ❑ Sipe: iamet <br /> er------ -------------------------------Depth-------- -----------• --------- ------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------.----------------------------- <br /> - <br /> ❑ Distance to nearest lot line-- -------------------------------------------------------•------------•--- --------- -------------------------------- ------------------- <br /> i <br /> Remodeling and/or repairing (describe):-___----..R,p+�-s=xx ._ �. - <br /> a 2-3o-9----------------------- ----------------------------••------•----------------- <br /> ------------------------------------ ------------------------------------------------ ------------------------------------------------------------------------------------------------------------------ <br /> ------------------!---------------------------------------------------------------•-------------------- ---------- ---------------------------------------------------------- <br /> ify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I hereby cert <br /> ordinances, State laws, a rules-and regulations of the San Joaquin Local Health District. <br /> (Signed)-------•---------------- --- - ---------------------------------------- - { ��Lirtg'Contractor) <br /> t <br /> �_ Title <br /> --------- ------------- <br /> By:-------•----- ------------------------ ------------------- ( ) i <br /> (Plot plan, showing size of lot, location of system in relatio to wells, build, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- - ------ ------------------- -- rF �-------------- DATE {t3-- -• -°� �--------------------- <br /> REVIEWEDBY------------------------------------------------------------------------------- --------------------- DATE---------`----------- -----`------------------------- <br /> BUiLDINGPERMIT ISSUED..---------------------------------------------------------------------------------------------------- DATE--------------------------- -------------------------------- <br /> Alterationsand/or recommendations:-. ---------------------- --------------------- ---------••-----------•---------------------------------------------------------------------------------- <br /> -------•-------------------------------------------••--------------------------- ---------------------------------------------------------------------------------------------------.--------. ....... .. <br /> ------------------------------------- ------------••------------•-----•------------------ ----------------------------------------------I--------- ------ -------------------- - <br /> 4 <br /> -------------------------------------------------------- -------------•------------------------------------•--.--•-------------- -----•---------- <br /> ' ------- ------ -- -------------------------- <br /> FINAL INSPECTION BY--------.1 <br /> Y:.----- 9 Date.... /v ��U - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M I0S2 Revised W-2100 <br />