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U <br /> 1 <br /> ��APP CATION FOR SANITATION PERMIT Permit N lu 7------ <br /> (Complete <br /> (Complete in Duplicate) �. <br /> U Date Issued/ <br /> Application is hereby made to the Sa-n 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. 5A9. <br /> JOB ADDRESS LOC TION-----�Z- --�--- - ------------------- <br /> - ----- ------- ---------- <br /> Owner's Name----- -- -• ------- ------- -------- --- ._ Phone--- 7-05 � <br /> --------------- - - - -------------------------------------------------- <br /> AddresS-------------------•-& to <br /> --------------------------------------------------------------- ----------------------­_­--------------------- <br /> Contractor's Name---- -------•------_---•- - ---------------- Phone------------------------------------ - ------------------------=-------------------------- <br /> Installation will serve: Residence <br /> +q�[� 'Apartment House ❑ Commercial ❑ Trailer Court ❑ _Motpal ❑ Other ❑ <br /> Number of living units: ___�4_ Number of bedrooms --s3- Number of baths ---� Lot size ___�`- -O "A� �1 <br /> -- --------------------- <br /> Water Supply: Public system Community system '� Private ❑ Depth to Water Table __. --- ft. <br /> Character of soil to a depth of 3 feet: S;�ONew <br /> Gravel E] Sandy Loam Clay Loam ❑ Clay ❑ Adobe�ardpan ❑ <br /> Previous Application Made: Yes ❑ No Construction: Yes o ❑ ` <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic ank: Distance from nearest well__��jj Distancit from foundation----/_i! Materi I--- ___________----------------------- <br /> ---------- <br /> _______ __________ <br /> No. of compartments-----------/moi___,-------Size------ -------- - <br /> '� X�_tau_Liquid depqth=----------T_---------CapacitY------�� ----_ 1 <br /> Disposayl Field: Distance from nearest well___ ._.._.Distance from foundajion______ __e,�___-Distance to nearest to lin <br /> I� Number of lines__________4-.___ f_Length of each line."_,0"00-*,'f Width of trench________ _"'t'_-_-_ _.C � r,Type of filter material __ Depth of filter material______,I_5 __.Total length __ <br /> Seepage Pit: Distance to nearest well-_____________________Distance from foundation-------------------- <br /> Distance to nearest lot line_________________ <br /> ❑ Number of pits_---T►- ------Lining material-----------------------Size: Diameter--------------_-- <br /> -------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation_._._.--------------Lining material____________-________ <br /> r <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid CapacitY----------------------------gals. <br /> Privy: Distance from nearest well--------------- Distance from nearest buildin <br /> ---------------- g-_------------- <br /> ---------- <br /> Distance to nearest lot line_______________________________,.,___________ <br /> Remodeling an_175 A - (describe) ------------ - � �. .. G le - i <br /> -------------- <br /> ----4!�7_ ;04 <br /> ------------------------ -----------•-` { <br /> =--------------------------- ------------------------------ ------------- ----- --- -- = ------------------------------------------------------------------------------------------------ <br /> I hereby certify that I have prepared this application a d that th work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and reuI tions of the n Joaquin Local Health District. <br /> (Signed)_ `��------ ----- ------------------------------------------------ (Owner and/or Contractor) i <br /> By:------------------------------------------•-•- ---------------- --------- -----------------------------------------------------.`Title <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., canbe placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------- ------- ----------------------------- --- --------------- DATE---f L <br /> ----------------------- - <br /> EDBY ---------------------------- DATE -;?------•--------- <br /> __ ---------------------- <br /> BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE <br /> Alterations and/or recommendations:---- ___..__________ <br /> ---------------------------------------------------------•------- ---•------------------- ---------------- <br /> ------------------------------------------------------•--------------- <br /> ---------------------------------------------------------------------------- <br /> -------------------------------- - _ <br /> FINAL INSPECTION BY----------------- - -------------------------------- Date----------J ------------ <br /> ----------------------------------------------------- <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreef <br />>- Sfockfon, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 <br />