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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <br /> Applicationff is hereby made to the San J.oaquin Local Health District for a permi to d6ristruct and install the work herein described. <br /> l sy <br /> T application is made in compliance with Count Ord', . nce No. 549, <br /> 'ON - -------------------- --- ------- ----- <br /> GG <br /> . ... ............. . ... --f <br /> --------------- <br /> JOB ADDRESS 0 AT <br /> Owner's Name-----------------------77�11:�------ ----------------------------- Phone-------------------------------- <br /> Address------------------------------------------------------------------------------------------------------------------------------------ <br /> --------------------------------------- ------------- <br /> -- ------------------ <br /> Contractor's Name--------------------------------115-vill"VA-VA�--------------------------------- -------------------------- ----------------- Phone----------------------------------- <br /> Installation will serve: Residence Apartment House Ej Commercial 0 Trailer Court [] Motel F] Other El <br /> Number of living units: ---- Number of bedrooms -?,--gumber of baths/------ Lot size ---- -- <br /> Water Supply: Public system E] Community system El Private;M- Depth to Wafer Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand Ll Gravel 0 Sandy Loam C1 Clay Loam 0 Clay [] Adob97eg_Hardpan E] <br /> Previous Application Made: Yes E] No,�LVew Construction: Ye�No 0 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> kpfic T kk- Distance from nearest well-----------------Distance from foundation_-------------.---_Materlai----------------------------------------------- <br /> ToAt� No. of compartments------------------.....:Size-. - ----------Liquid depth------r------------------Capacity--------------------- <br /> Disposal Field: Distance from nearest well_ __i 45 -7-pistance to nearest lot liner <br /> =,-Ae�------Distance from foundation-- ---- <br /> NU lines-_-- Length of each line------ -,57VWidth of french. ------- <br /> mber or ---- ----- Lenc <br /> or <br /> Type i filter material---,:5ir1__J?-lk6epth of filter maler�al--- ---------Total length-------- <br /> Seepage Pit Distance to nearest well----------------------Distance from foundation----..-__----------.Distance to nearest lot line--..--------_.-.-I <br /> Number of pits----------------------Lining material-----z ----------------Size, Diameter---------- ------------Depth----------------------------- <br /> Cesspool: 1/ Distance <br /> epth----------------------------- <br /> Distance from nearest well-----------------Distance from foundation------- ----------Lining material-_.-------.----.---.__-----.---- <br /> Size: Diameter-------------------------- ...........Depth----------------------------------------------------Liquid Capacity----------------------------gals.'A <br /> Privy: Distance from nearest well---------------__-----_---------__.-- ------Distance from nearest building-------------------------------------- - <br /> ElDistance to nearest lot line--------r- ----------------- -------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/of repairing (describe):---------------------- ------I-------------------------------------------- I------------------------------------------------------ <br /> - <br /> ---------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------I------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------- <br /> - <br /> ------------ --------- ----------------------------------------------------------------------------------------------------------------------11------------------------------------------------------------------------ - <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 law , and rules and regulations of the San Joaquin Local Health District.- <br /> -------------------------------------------- ------------------------------------- <br /> (Owner and/or Contractor) <br /> By:-------------------------------------------------------------------------------------- ----------------I-- ------------------------(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 /> - DATE <br /> APPLICATION ACCEPTED BY---------------------- --- --- ----------- --V----------------- ----- -- <br /> --------- -------5---------------- <br /> REVIEWEDBY----------------------------------- - ------- - -------- ------------------------- DATE------------------------- <br /> BUILDINGPERMIT ISSUED----------------------------- -*--------------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations:----------------- ----- ----------------------------------------------- ----------------------------- --------------------------------------------- <br /> --------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------........ ---------- <br /> --------------------------------------------------------------------------------------------------- ----------------I------------------- ------------------------------------------------------------------------------------- <br /> --------------------------•---------------------- -------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------- --------------------- -- -------------------------- ------------------------- --------------------- ------------------------------ <br /> ----------------------------- <br /> FINAL --------------------------------- <br /> INSPECTION BY---------- a----( L- ------- ----------- Date------. ------�-/ X�,>------------------------- <br /> "!J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West 0A Street 132 Sycamore Street 814 North "C" Street <br /> Sfock+on, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 <br />