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t° �1i <br /> APPLICATION FOR SANITATION PERMIT Permit No S <br /> �I (Complete in Duplicate) <br /> Date,issuede/Q''-'?-_ _'--`-__-•-- <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct ari`d install th lwork herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> i f <br /> JOB ADDRESS AND LO AVON ----------- { r' <br /> .( <br /> Owner's Name = --- `_*--- t!`".--------------------------------------- <br /> -- -- --------- ----- <br /> .._. <br /> Phone------ <br /> = 'Address - <br /> _ _ ------------------------------•-----•------------------------ <br /> ------_.•-------------_= <br /> ----- - <br /> Contractor's Name--•- ---- ------------ Phone------ <br /> ----------­------------- -. -= <br /> Installation will serve: Residence Apart nt House Commercial Trailer Court ❑ Motel ❑ Other ❑ 3 , <br /> Number of living units: Number of bedrooms _-. Number of baths ._ .-- Lot size'__-- d_----------------D ... <br /> Water Supply: Pu6#ic system-alCommunity system ❑ Private ❑ Depth to Water Tablft. - <br /> Character of sot oa depth of.3 feet: ,Sand ❑ Gravel E] Sandy Loam E] Clay Loam E3 ' Clay ❑ •AdobeK Hardpan [-] W <br /> Previous Application Made:� Yes ❑ Na"� New Construction: Yes No E] ' <br /> TYPE OF-INSTALLATION-AND SPECIFICATIONS: <br /> � �/�\ a <br /> (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) 7 + <br /> b <br /> Septic T nk:' Distance from nearest well-----------------Distance from foundation-------------------.Material---------- ___-_.__---_____________-______._____- <br /> No. of compartmeln,Fs-------------------------Size---------------•----------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal F' d: Distance from nearest well---------------_.Distance from foundation---------------------Distance'to nearest lot line_________________ <br /> Number of lines__--°---__________________ _____Length of each line------------------------ of trench-----------------------------_--_-- <br /> I <br /> Type of filter material-------------------------Depth of filter material------------------ <br /> �, `----Total length------------------------------------------ <br /> ..,.�,.�„ �.. t _ <br /> Seepage Pit: Distance'to nearest well ?�t�-_'-_--Distance m fa ation__-6__-----Distance rto nearest lot <br /> line-Number of pits-__.___/-----------Lining material __ e_ --Size: Diameter-_-__ _. Depth_____-_'_�_��_.�-'� <br />~ Cesspool: Distance•from nearest well-----------------Distance from foundation--_----------------.Lining material---------------------------- <br /> ❑ Size: Diameter----- -------------------------------Depth---------------- -------------.---.---------Liquid Capacity---------------------------._gals_ ; <br /> Privy:, Distance from nearest well------------------------------------_------------Distance from nearest building__-_-______---%-"_________ .: <br /> Distence to nearest-lot line__.__._._________ ________ _._ <br /> - ---------- <br /> ❑ -- - - ------------------•--•-- --`--=--•-----------------------------------------------=---------- <br /> describe :-------- <br /> Remo�elin repairing <br /> -• ------------------------------•---------------------------- --------- --------------------------------------------=--- ------ ` -------• - ------ <br /> ------------ --------- <br /> ---- -- ----- ---- ----- -- -----------2.-------------------------------------------------------------------------------k----- <br /> ------•-•--------------------------------------- <br /> ----------------------------------- <br /> - ' ----------- <br /> -- - ------------------------- - - % ------------------------- <br /> ------------------------------------------- ---------------------------------•-----------------------------•------•---------------••------•------•----------------------------------- <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State sand rut and regulations of the San Joaquin Local Health District. z ;, <br /> (Signed)---- ---- ---- ---------------------------------------------------------- --------------------- Owner and or Contractor <br /> By: I-------------=----------------------------------(Titl __ �•r- <br /> `(Plot plan, showing size of lot, location of system in relatioA to wells, buildings, etc., can be ed on reverse si e). ` <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__ I -- DATES- <br /> REVIEWEDBY--------------------------- -- ----------------------------------------------------------------------- DATE _ i <br /> ----------------- <br /> BUILDING PERMIT'ISSUED--------------------- -•----•----------------=---------------•-------------------------------------- DATE------- - <br /> Alterations and/or recommendations:----------------------------- ---- I- <br /> -------•-------------------------------------------------•----- ----------------------------------------------------------------------.... -------------------•----•----•-------------•---•-----•------------••---------- <br /> ---------- , ' <br /> - ------------------------ -- <br /> 4 1. 4 <br /> - ------------------------------------ --------------------------- ------- ---------------------------------------------------------------------------------------------------------------------•----------• ------------- <br /> pyFINAL INSPECTION BY: :-4------ -=----- - --------- Date-. ------ ---- <br /> 1. 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 ; Revised W-2100 <br />