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APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------------ - __- <br /> (Complete in Duplicate) pate Issued" '` �. <br /> ,• - _..� .�. ...,. ,� ..,. ---'I •=-'-------• <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 L CATION :;� = ---c-`-'-`-=�--- --- <br /> n - - <br /> Owner's Name------------- T "/ --- - -- - ------------------------- ------ Phone _ /?---••--- <br /> Address____! a 2U---- _ 7 <br /> Name___________________�j ,�_ ��-__ Phone.. ___ ____ <br /> t`' ----- •----- ---- <br /> Contractor's <br /> y �.�:..� ••rte ,-.�-�-..� � � ❑ - <br /> Installation will serve: Residence O Apartmen House ❑"'Commercial f 7Trai[er Court ❑ Motel ❑ Other <br /> 'Number of living units: _-�__ Number of b, Brooms __-3_ Number of;baths dot size <br /> -- u -.{ ` <br /> r Water'Supply: Public system '❑ Communi{y system ❑ -Private� epth,to Water Table ��_ ft. <br /> Character of soil to a depth of 3 feet: Sand❑ Gravel 0 Sandy Loam E] Clay�Loam ❑ "Clay ❑ Adobe Hardpan ❑ � " <br /> Previous Application Made: Yes ❑ No New Construction: ?Yes[ No <br /> �'" d. <br /> TYPE OF INSTALLATION AND'SPECIFICATIONS "" <br /> (No septic tank'or cesspool permitted'`if publicsewer is available wi hin(200 feef.), T . <br /> Septic Tank: Distance #rom nearest well__ Distance from foundation____:�'S__:_____,Material_____ ' •---------_-:___. <br /> No {of compar#merits------ ------- Size�-- 6---- - 1�----...Liquid depth---.--lj�-Z.--------Capacity.--.----�� <br /> Disposal Feld: Distance from nearest well__�Q__�''__.'Distan`ce from'foundation__�47_'_I-----Distance to nearest lot line.:__30_-_-. <br /> :, <br /> Number of lines___.__-.�_-__:_ _ Length •of each line-kS________________Width of french___.__ ______________-__-.-_ <br /> p P� " { <br /> Type of filter material__S_-CF ''"'-Depth of filter material____�.o_-.,___ __Total length---------7-S__________________________ <br /> Dist <br /> to <br /> Seepag =0300 Numberofof pits resell_��i�ng rnaQteraa(e- -rom�fo� S zre nQ ameter._-_,�/� rice topeea+nsDi I t lo�ise�-vd--�.---- <br /> 0 . <br /> Size: Diameter____-_. --- _------ <br /> Cesspool: Distance from nearest we„I_ Distance frohi faundat .---------- 4._..1iming material_______.__-____--- <br /> z, De th ` -----=-----------:Liq id Capacity 9ais. =. <br /> Privy: Distance from nearest wl--- <br /> ---------------------------------------------Distance from nearest building--------------------------------•--------_- <br /> ❑ Distance to nearesttlot line"°""_::-” <br /> r --------------------------- -----------------------•-••--------------- --------------------------------- -------=- <br /> Remodeling and/or repairing (describe)____________________ <br /> ------------ --•------------•--•----------•-•------•----------------- <br /> i <br /> ______________________________•_•-_.______--__.__ S <br /> ------ ---- ----- - -- ---- ----- - --- ---- --- ----f ---------------------­-------------- ------------------ -----------------------------------------•------------------------------------ <br /> I herebycertifythat I have re aced this application and that the work will be done'in accordance with San Joaquin County <br /> ordinances, State laws, and rules and re ulations of the San Joaquin Local Health District. y <br /> (Signed) ;�? <br /> - -- ------------------------------------r--- ----------- O <br /> w er and/or Cont-rsaec..to�r <br /> -. f <br /> ) 0 <br /> (Plot plan, showing size of lot' location of system ' relation to wells, buildings, etc., can be placed on reverse side). <br /> G <br /> FOR'DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------------------------------- ------ DATE : - <br /> ' ----------------------------------: ------ ----- --• <br /> -- <br /> REVIEWEDBY - -------------------------------------------- -------------------`-----------_---------------------------------- DATE--------------------------------------0------47r------------- <br /> BUILDING PERMIT ISSUED------------------- 1-----------------------------------------------------------••--------­--------- DATE <br /> Alterations and/or recommendations-------=_------•--------- -------------------------------------------------•---------= <br /> --------------------------------------------------------------•------------------------------------------ -. <br /> ---------------------------------------------------------------- ------- -------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------- ----•-----•-----------------•----------------------••------------------------------I------- <br /> FINAL INSPECTION-BY:.----------------------- --`----v ---------- :. - Date. - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2 MS Revised W-2100 <br />