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o� <br /> APPLICATION FOR SANITATION PERMIT Permit No9*04 <br /> _ <br /> (Complete in Duplicate) <br /> Date Issued ------- <br /> r/ � <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 LOC TkON__Z .x �/ <br /> / t. <br /> Owner's Name__ @ -C• , � .. ---- Phone-'?3K?- - ---- . <br /> Address___ <br /> Contractor's Name.------------------------ ------•-----•--••---------------•----------------------- 4--- ---------------------••-----------------•-• Phone '�"�...�= <br /> Installation will serve: sResidence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ //M''otel D Other ❑ j <br /> Number of living units: __-____ Number of bedrooms __ - Number of baths ___I____ Lot size ____- __0_.______________________ ' <br /> 9� <br /> Water Supply: Public system ❑- Community system X'.Frivate ❑ Depth"to Water Table +- <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: YesX. .No ❑ 1 <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 well__ 4 --Distance ro f s datlon__A- --------- ial_ _�__ _ <br /> -- -.Li uid de th____ Ca aci <br /> d <br /> [� No; of compartments____.- � Q p. �-- p tY--��-��--- <br /> • ^ p ""' s�r Distance.to,neares lot line__ I <br /> Disposal Field: D stance from nearest well-: .--Distance from foundatio __ ,---------- <br /> �. _T ,- _�4 .--. - i 5�a g er <br /> Number•ot -T - 'Length of each line=____:_ ___ Width of trench <br /> Depth <br /> c-r . ri µrr - r <br /> a L <br /> cR: Type of fil�•er material-4- --------Depth of filter material_._.__� -__- •---- <br /> . - �� � i n____ :----Doistance to nearest line_____. . <br /> Seepage Pit: Distance to nearest well:"'.----7-_ =_.___-_ 'Distance from foundet•o <br /> ❑ Number of pits------------------ Lining - 5ize: Diameter----------_-_ _------Depth------------------------- <br /> Cesspool: Distance from nearest well_____---------___;Distance from fouhd�tion__._____-__--F____.Lining material_.-____________-___ `___-_____. <br /> ❑ $ _____-_Li Liquid Ca aci <br /> Size: Diameter-------- -- `��, Depth p :. Q- ..F.p......------------------------------gals. <br /> Al- '..i $ 'G' �" "�'Distance from nearest buildin <br /> Privyri "Distance rom nearest well 1 --µ�� -------- g -------------------------------------- <br /> ❑ ----------------------- -. -- <br /> Distance to -nearest'Iot•line--_:__-_��__.""______.:_- ' ` - <br /> Remodeling and/or repairing (describe):-------------------------------------_______i_________________----------------------------------------------------------------------------------------------- <br /> + <br /> t - <br /> ---------••-------•--------•--•-•-•------------•--=-=--------- <br /> - <br /> E ` . <br /> { <br /> I hereby certify that.l•have prepared Phis a plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, State I and r and .regulatio s of f San Joaquin Local Health District. <br /> -------- ----- Contractor <br /> ( wne and/or <br /> .(Signed)-------- --------------• - - - <br /> By:------------------------------ -t------•-----------------------------t--------.-----------------------------------•-------------------(Title)--•-•------------------------------•--------- ------- ----- 4 <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 /> APPLICATION ACCEPTED BY =-_' ------- - = --------- ------- ------- DATE------- ---- ---------------------- <br /> ---------------------- <br /> « } k <br /> REVIEWEDBY--------------------------- "_" "------------------------------ -------------------=------------------------- DATE = <br /> BUILDINGPERMIT ISSUED-----•-•------•---------- ----- ----------•---------•------------------------------- DATE------------------------- ---------•--------- 7 ----- <br /> Alterationsand/or recommendations:----- ---- ------------------------------------------••--------------------------------------------- --. ---------------• -------------------•---•--- <br /> I -------------------------------•--------------------------••••--------------------•----------- <br /> -------------•------------- ------------------ <br /> --•----------------•--------------•-- -----------------------....... <br /> •------------/----------•-------•------- <br /> FINAL-`INSPECTION BY .- '� �'---- =--- Date_ -. ._ �7 7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street•-� .} a V300 West Qek Street �,� 'x,.132 Sycamore Street 814 North "C" Street <br /> Stockton, California .y,k Lodi, California Manteca, California Tracy, California <br /> t <br /> ES-4-2M Revised W-2100 <br />