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APPLICATION FOR SANITATION PERMIT 0 Permit No, ---- <br /> --") � <br /> (Complete in Duplicate) <br /> Date Issued <br /> Applica4-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the w rk herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> —2 <br /> JOB ADDRESS AND LOCATION----Z;----------------- --- --- ------------- <br /> Owner's Name--- ----- ----- - ----- ------- -------------------------------------- --------- <br /> f <br /> Address----7---------- ­---------------- ------------ ----I- --------------------------------- ---------------------------------------------- ----------------------------------------------- <br /> fJ <br /> Contractor's N'ame' ------------------------------------------------------------------------------_---------------------- Phonel <br /> Installation will serve:----Residence Apartment House E] Commercial [-I Trailer Court 0 Motel El Other El <br /> Number of living-units: _1--- Number of beclroon+r,�... Number of aths J--- Lotsize ----- ---cl.---------------------- <br /> Water Supply: Public system E] Cor6unity system E] Private of <br /> to Water Table -------- ft. <br /> ISa,d.'El Gravel ❑ Sandy Loam El Clay Loam E] Clay E3 Ad.be 2( Hardpan C-]� <br /> Character of soil to a depth of.3 feet. <br /> Previous Application Made: Yes E] No 2-- Now Con.struction. Yes EVN' El <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 ----Distan n------LQ------ Material________--------Chl-4- <br /> 4 �j from fWn�afio ate 11 ---------------- <br /> No. of compartments_ - --------Size_ Liquid clep�h-------4-------- --------Qapacity-----9e_D_j0___ <br /> Disposal Field: Distance from­nea'rest well.._%_'5�f, '-Distance from foundation_____2.__3__._.Di5tance'to neat est lot line--/-5-------- <br /> Nu'M' ber ------- ---C_-Len96 of each of trend,1______71----------------------- <br /> Type of filter maferial____��,_ ___ --Depth of fisher material-----/4_f------Total length--_,:: ----------------- <br /> Seepage Pit: Distance to nearest well-______________ Distance from foundation--------------:----.Distance to nearest lot line__--____________-❑ <br /> of pits"- ------- ------Lining---------------Lining material..---------------------Size: D�ar�6ter--------- I - <br /> --- --------------Depth------------------------------- -- <br /> Cesspool: Distance from'nearest'w' ekl-----------------Distance from foundation--'_--,------ ---- Lining material l----------------------------------- <br /> ❑ Size: Diameter--------------------------------------Depf h---------------------------------------------------Liquid Capacity----------------------------gals. <br /> - e <br /> Privy: Disfance'from nearest well----------------------------------------------7-615fan, from nearest building_____ ----------------------------------- <br /> ElDistance to nearest lot line---------------------------------------- --- --------------- --------------I—--------------- ----------------------------------- <br /> Remodeling and/or repairing (describe):--------------------------------------------------------------­--------------------'---------- ------------------- --•--------•----..._....--•--------- <br /> r <br /> -------------------------------- <br /> 1---------------------------------------------------------------------------------------------------- -------------------------------------------I---------------------------------- <br /> t -----­------------- -------------------------------- <br /> --------------------------------------4­­­-------------------------k,----- --------------­------------ ----------------------------- -------I---------- <br /> ------------------------------------------------------------------------------------------------------ ------------------------- -----------------=------------------- <br /> I <br /> ----------------I—---------------- <br /> I-hereby certify that I have prepared thus 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 /> /)A -r and/or Contractor) <br /> -----------01-Y"------------------- ------------------------------------------------------ --------------(Ow <br /> (Signed)---------------9 _ _ ___e <br /> By:-------------------------------------- --------It------------------------------------ <br /> --------------------------------------------------------------------------------(Title)------------ <br /> (Plot plan, showing-size of lot, location of system in relation-to wells, buildings, etc., 3 n 6� placed on rever4l side). <br /> 9a e <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- ------------ ....................... DATE--- C? 7 -_---------------------- <br /> --—---------------- <br /> ------------------------------------­ DATE---------- ----------------------------- <br /> REVIEWED BY--------------------------------------- -------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------- --------------------------------------------- DATE----------------------- ------------------------------------ <br /> Alterations and/or recommendafions:----------------------------------------------------------------------------------­-----------------------------------i <br /> Ir <br /> I ----------------------------------- <br /> ----- --------------------------------- ------------------------------------------------------------------------------------------------------­­­------------------------------------Ir------------------------------------ <br /> --------­---------------.........­----------------------------------................. <br /> ------------------------------------------------------------------Tr-------- ----------------------------- -------- <br /> ------------------------------------------------------------------------------------------------:%Z-----------------------------------------------I-------------------------------------11------------•-------------•----------- <br /> -------------J!------ ----------------------- <br /> --------------------------------- -------- -------------- ------:------------------------------------�­----------------------------- <br /> -------------------- <br /> FINALINSPECTION-BY:.<;9 ---------------------------- Date--- ----------- ------ ---------11------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Sfreef 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tri cy. California <br /> ES-, 9-2M Revised W2100 <br />