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APPLICATION FOR SANITATION PERMIT Permit No. __,.5_._�_`�T <br /> (Complete in Duplicate) Date Issued .-_1L;�7//, <br /> 4 <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 County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION--,b-- - J <br /> Owner's Name__l.rf --- T -------- <br /> � <br /> P one------------- <br /> Address. = = -- ----------------------------------------------•------------------------------------ ----------------------------••---------•----- <br /> Contractor's Name----- - ---- - ---------------------•------•-----•---------------------•----------------------------------------------- Phone-----------------------_--------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: j____ Number of bedrooms '__ Number of baths /____ Lot size .�---to-----__J._4`Z)------------------------- <br /> Water Supply: Public system 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< Hardpan ❑ <br /> Previous Application Made: Yes ❑ No-,F�m( 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 /> Septic Tank: Distance from nearest well_N,0-,t1__*_Qistance from foundation---1-0---------Material------_ e_�4_�^-+ ----------- <br /> xNo. of compartments__-_�---------------Size--- -- -,Si- - --------Liquid depth_-._--__---------------Capacity-___--_!�a_ <br /> Disposal Field: Distance from nearest well A/6.4-fDistance from foundation----J_/„7.--------Distance to nearest lot line____e5_11- <br /> Number of lines___-_______ _ _ <br /> __ _ __._._____Length of each line__,�_]Ll?.......__j___.Width of trench--- ___________ <br /> Type of filter materia Depth of filter material---q-p__G ( Total length-----LZ� � <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line____--___________ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--_---------------.-------------- (� <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------- <br /> ❑ "�� <br /> Size: Diameter--------------------------------------Depth------------------------------ --- -----------------Liquid Capacity- --------------------------gals. Q. <br /> Privy: Distance from nearest well-------------.-----------------------------------Distance from nearest building--------------------- _.__________________- <br /> ❑ Distance to nearest lot line----------------------------------------------- ----------------------------------------------- ------------------------------------- <br /> Remodelingand/or repairing (describe):------------------------------------ ----- ----------------------------------------------- ---------------------------------••-----------•-------- <br /> --------------•-•--------------------------------------•-------------------------------------------------------------------.......---------------------------------------------------------••------•------------------------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. . <br /> (Signed)- 8-;0--- - - - -- ----------------------------------------------------------------•---------------------------(Owner and/or Contractor) <br /> By:-----------------------------------------•-•---------------------------------------------------- -- ------------------------------(Title)---------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------ ------------------------------------------------•--------- DATE-------- <br /> REVIEWEDBY------------------------------------------- - ---- ----------------- DATE-------------------- <br /> -------------------------- <br /> ---- --- ---------- ---------------------------------------- <br /> BUILDING PERMIT ISSUED------------------- ------ DATE-------------------------- ` , <br /> Alt ions nd or recommendations:____-_-___ __ - --- <br /> ------------- <br /> ------------------------ -----------------------•--_­--------------------- ................. <br /> ---------- ------------------------------------------•------- ---------------------•--------------------------------------------------------------• •-•---•- -------------------------------------- -------------------------- <br /> FINAL INSPECTION BY:--- s---------------------------- <br /> ------------ Date......... _._- ):—� <br /> - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street <br /> Stock+on, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ; Revised W-2104 <br />