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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issuecll:� ��7�- <br /> 0q10-3 -7 Vy/ <br /> Application is hereby made to the San Joaquin Local Health District for 6 permit to construct and install the work herein described. <br /> This application,.is-mad-_>.--,,:ompIian-ce with County Ordinance No. 549.kq - <br /> ADDRESS <br /> Nal �O lcj �Q <br /> JOB ADDRESS A <br /> NaIlk. <br /> Owner's Na 7 <br /> --- --- PhoK"6------------------------------------ <br /> JLZ ------- <br /> ------------------ <br /> Address........ <br /> ----- -------------J - ----0---------------------- - - ------I--------------------------- ---------------------------- <br /> Contractor's Name-------- ---- ------------------ ­-------- L___ <br /> ------------------------------------------------------------------------------------ ---------- Phone----------------------------------- <br /> n Motel 0 Other E] <br /> Installation will serve: Residence Apartment House El Commercial 0 Trailer Court E_ <br /> Number of living units: ---- Number of bedrooms --l—Number of baths I---- Lot size --- -------------------------------------------------- ---- <br /> El <br /> Water Supply: Public system 0 Community system Private Depth to Water Tablplbft. <br /> Character of soil to a depth of 3 feet: Sand Ej Gravel E] Sandy Loam * Clay Loam El Clay E] Adobe E] Hardpan E] <br /> Previous Application Made: Yes No New Construction: Yes 1 No 0 <br /> TYPE.OF INSTALLATION AND SPECIFICATIONS: 41 <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance fr6m,nearest welIJIS7 Dist erf r 3oa.i o on-�__��Pt�__Moer-ia ---- <br /> No. of co mipartments.........z, ------X......��Liqcl ------------Ca city------ <br /> Disposal Field: Distance from nearest well_A�J_ Distance from founclatio Distance to near!eiTt IV '11' <br /> ------------ <br /> t <br /> --j-_-_Depth of filter material--/-;?.- .. <br /> Number of line Length of each line-_2 -6- �Wiclth of tren -------------------------------- <br /> Type of filter material-.2t 17- _L ------------Total Ieng+h__,_/_.)-_8__,--.__--__________--__. <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation------------_------Distance to nearest lot line__._.-____.__..._ <br /> ❑ <br /> ine----- ----------- <br /> El Number of pits---------------------Lining material-----------------------Size: Diameter------------------------Depfh------ ------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------Lining material___-_-__________-__._-_____-___---__ <br /> ❑,�:.. Size: <br /> aterial------------------------------------- <br /> Size: Dia mete ------.-------zi.Dop-th-------------------------------------------------------Uquid Cap cilt ; - ----gls.,%b I <br /> Privy: Distance from nearest well------- -------- --------------------------------Distance from 'nearesf building_--________.______________--______-_-._... vl <br /> ❑ <br /> uilding------------------------------------------ <br /> El Distance to nearest lot line--------------------------------------------------------------------------------------- <br /> I <br /> Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------ ----------------------------------------I--------------I-------------------------------------------------------------------------------------------------------------I----------------------------------- <br /> ---------------------------------------------------------------------------.1------------------------------------------------------------------------------------------------------- ----------------------------------- <br /> ---------------------------------------------------------------------------------------------I------ ----------------------------------I------------------------------------------------------------- --------- <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, Stafelkws, <br /> ,pd.,rules and reg fila+tons/of the San Joaquin Local Health District. <br /> --------- - - ----- <br /> (Signed),__.,,e.1_e!!!eve�------------ ------------------------------------------------------------------------------(Owner and/or Contractor)' <br /> By�----------------------------------------------t----------*------­--------------------------------------------------------------------{Title)--------- <br /> ---------------------(Title)--------- --------------------------------- - - ----------------- <br /> (Plot plan, showing size of lot, locationI of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> oe <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ------------------------------------- DATE--------- �� <br /> REVIEWED <br /> ATE---------- <br /> REVIEWEDBY--------------------------------- ------------------------------------- DATE_---------------- <br /> BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE <br /> Alterations and/or recommendations:--------- ------------------------- ----------------------------------------------------------------- <br /> ­­-------------------------------------------------------- ------------- - -------------------------------------------------------------------------------------------------------------------------- -------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------*-------------------------- <br /> --------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- <br /> --------------------- ------------------ ------------------•------------------•--------------- ------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION <br /> ...... -------------------------------- ------------- Date__ ­ ------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manfeca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 <br />