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APPLICATION FOR SANITATION PERMIT Permit No.-,�_-;___ <br /> (Complete in Duplicate) <br /> Date Issued15 <br /> Appli a+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 w,�itth County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION--4 1P-r�-- --_f--- ---- - ------------------------------------------------------ <br /> Owner's Name---------------------4- - s-�--s---- O- ——lEB-A----1--- -------------------------------------------- Phone-----�"`-------- <br /> - <br /> Address------------------------- MV�---------------------------------------------------------•-------------------------------------------------------------------------•---- j <br /> Phone- <br /> Contractor's Name_-. �''l., n+►,. -1''i--t'�'�------------------ -------------------------------------------- <br /> Installation will serve: Residencel�. Apartment House ❑ Commercial (] Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __Number of bedrooms _ __ Number of baths I �_ ___�__��_'__�'r_______________ <br /> Lot size __-.-- <br /> Water Supply: Public system A Community system ❑ Private ❑ Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ CI oam El ,Clay F-1 Adobe 11 Hardpan El <br /> Previous Application Made: Yes E] No I� New Construction: Yes ❑ No /Gi�1.18..0 ..� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> e ti Distance from nearest well-----------------Distance from foundation-------------------Material___._____._____________.____________________-. <br /> No. of compartments--------------------------Size-------------------------------•Liquid depth----------- --------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line___-___-____-_--- ` <br /> ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench.---------------------------------- <br /> Type of filter material_________ _____________ epth of filter material__-____ -----------Total length________._______________________________._ 6 <br /> Seepa e Pit: Distance to nearest well_______.__ ___Distance fro fo ndation_. ._.._______.Distance to nearest lot line---- _- I✓ <br /> Number of pits------ -------------Lining material. 60 <br /> -Size: Diameter--- ---_____.Depth___ j -____________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material____________-___.________________ <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity. ----••-------------------gals, <br /> Privy: Distance from nearest wO-------------------------------------------------Distance frorrinearest building------------------------------------------ <br /> F-1 Distance to nearest lot line------------------- ---------------------------------=--•---•---------.---------- ------- <br /> Remodeling and/or repairing {describe):---------------------------------------------------------------- <br /> ------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- <br /> ---------------------------------------------------------I-------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------••-•------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------- ---------------------------------------------------------...............--•-----------•----- ..�._.. -----------------------------------------------------...-------------------------------- <br /> I here ter that I have prep red this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State la s, and r les and egulations of the Joaquin Local Health District. <br /> (Signed)---------- - ---------- -- ---- ----------------------- ------- - - -- -------------------------------------- ( e+' Contractor) <br /> By:------------------------------------------------------------------------------ -- -- - - ------ ---------------------(Title] -- <br /> (Plot plan, showing size of lot, location of system in rel ti to wells, buildngs, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY { -------------------------------------- DATE s --------------------- <br /> REVIEWEDBY------------------------------------------------------------------------- ---------------------------------- •-----•-• DATE----- -­/----------- - -----4-_-------------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE---•------ --------------- <br /> Alterations and/or recommendations------------------------------------------------ -------------------------------•------_---------------------------------------------------------..---------.-.. <br /> ----------------------------------------------------------------------------------------------- --•----------------------•----------------------------------------------------------•-------------------------------------- <br /> ---......-•------------------------------------------------------------------------------------------------ -----------------------------------------------------------------•----..--------------------------------- <br /> ----------------------------------------- ---------------------------------------------------------- -----•---------•---------------- ---------------------------------I----------------- -•---• <br /> i,57//,W/ Is-- 1�S- - j-C <br /> FINAL INSPECTION BY:-----------------ll-_- f- -------/; Date------------------------------------------------- / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street .132 Sycamore Street 814 No <br /> Stockton, California Lodi, California Manteca, California Tracy, <br /> ES-9-2M ; . Revised W-2100 <br /> 3 <br />