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fPermit No. _ - --- <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> -�- <br /> Date Issued ----------------�--�=� .� <br /> q <br /> Application is hereby made to the <br /> 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 Ord ante No. 549. <br /> S AND LOCATION-____ 1 <br /> JOB ADORES .Z / ®' / �` 'r ........ <br /> - <br /> Owner's Name------------ ------------ �7 -------------------------------------- Phone-------------- ----------------- <br /> ------------ -- - <br /> Address.. -�� " ------------------------------------------------------------ = <br /> -------•---•---- � � <br /> QhJLr�- �'4 ---- ------ Phone___. _.-=--x0-D�------ <br /> Contractor's Name--------------------------------- --- -- - ---------•----- --- - <br /> Installation will serve: Residence tt Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___j___ Number of bedrooms _-V- Number of baths ___j__ Lot size ____ - -j-- -- <br /> 40 <br /> Water Supply: Public system %_ Community system F1Private ❑ Depth to Water Table W ft. <br /> Character of soll to a depth of 3 feetI Sand E] Gravel ❑ Sandy Loam ElClay Loam ElClay ElE]Adobe Z Hardpan <br /> i �} p <br /> Previous Application Made: Yes E3NoNew Construction: Yes F] No ❑- .,.r <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or_cesspool per'mitted if public sewer is available within 200 feet.) <br /> i <br /> Mxn--7 <br /> k: Distance from nearest well________________Distance from foundation--------------------Material--------------------------------------------____- - ; <br /> N0.1 f compartments - depth--------------------------Capacity----------------------- <br /> Di Disal Field, Distance from nearest well-------------------Distance from foundation______________._:_.Distance to nearest lot line----------------- <br /> Number of lines------------•----------- ---- -----Length of each line_---------------------------.Width of trench----------------------------------- k <br /> Type of filter material_________________ <br /> --------Depth of filter material-----------------------Total length------------------------------------------ <br /> 0' <br /> ----------------- .-----�i <br /> Seepage Pit: Distance to nearest well_._ ik�tt9i.l,a---:-Distance from foundation!_____.____--Distance to nearest I line___J ------- <br /> --- <br /> Number of pits_-----t--------------Lining material_ ----Size: Diameter-_-- ----------Deptn----------�---------------- <br /> Cesspool: Distance from nearest well-________________Distance from foundation--------------------Lining material__________________________________ <br /> ❑ ---------Depth---------------------•-----------------------------Liquid Capacity---- ------------------gals. <br /> r �l <br /> ------------------------ <br /> I .__Distance from nearest buildin ----------- <br /> ------------- <br /> -- - <br /> • Distance m from niearest well ------------- -- 9--------- ---------------- ------- <br /> Privy --------------------- <br /> ❑ Distance to nearest lot line-- -------------------`- ----- <br /> ---•--`----- <br /> 1 Remodeling and/or repairing (describe):-------------------------- ------------------------ ' <br /> I 7 <br /> ==------------------------------------------= -----------------------•---------------------- <br /> t . - - ------- -------------- ---------..._.. <br /> i ------------------------------------------------------------ <br /> ---------------------------- <br /> I hereby c rti that I have p ared this application and that the wor "will be done in accordance with San Joaquin County <br /> ordinances, Sta a ws, and rules a' d regu of the San Joaq o Health District. <br /> (Signed) Contractor) <br /> ----------- <br /> By;•-----------_-•------_-----7 ----------• ----------------------- r..✓ = )Title)---- .5"- .J�z7W—- Zt/-------------- <br /> (Plot plan, showing size of lot, loca 'on of syste in' elation to wells, b di s, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------------ _ __ _ DATE---- -------_ <br /> f - .r =: -� ----------- DATE--- -- -- ------------I----------------•---------- <br /> REVIEWEDBY--------------------------------- <br /> 1 DATE.--------------------------- ------------------• ---------- <br /> BUILDINGPERMIT ISSUED------------=-t--------------------- ------------------------- ------------------------ <br /> •---------------•-------•----•--------"----------------------•---•--------.---------•-----------•-------------------------•- <br /> Alterations and/or recommendation : <br /> ------•"----•----------------- <br /> j i <br /> ._.._..---•--------------------•--------------•--------•---•-- — — <br /> --- ----------- ------------------------- <br /> ------------------------------------------------------------ <br /> --------------------------- <br /> I �F{NAL INSPECTION BY------ ----- - -- -------- --------------- - ------------ Date----------�[:o-- ----------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 134 South American Street E <br /> 300 West Oak Street 132 Sycamore Street 814 North "C' Street <br /> Lodi, California Manteca, California Tracy, California <br /> Stock�on, California <br /> - -SES-9-2M 10-52 Revised W-2100 <br />