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APPLICATION FOR SANITATION PERMIT Permit N6, - ----------------------- <br />(Complete in Duplicate) Date Issued --- <br />A <br />�plica-�ion is hereby mads -to the San Joaquin Local Health District for 6 permit to construct and install the work Iherein described. <br />This <br />application is made in compliance with County Ordinance No. <br />JOB ADDRESS AND LOCATION----- ------- ---- ----------- ---------- ------ ........ ------ ........ ----------------- ! ----------------------------- <br />OwnersName__ I ----- --- ---------------------- -------------------------------------- Phone.-_-! ----------------------------- <br />71-3 ------ - &.A- ---------- -------------------------------------------------------- ­­ ............ <br />Address ---------- -- ----- ------------- ­ ------------------ ----------- <br />Contractor's Name --- -------- -------- --------- Phone__� <br />01� <br />Installation will serve: Residence- �67rmen_i House [I Commercial 0" Trailer Court El Motel E] Other F] <br />Number of living units: _J___ Number of bedrooms _2_. Number of baths ___/__ Lot size --- AA_AL-'?__________-"_--____-__ <br />P <br />Water Supply: Public system &GOmmunify system E] Private [] Depth to Wafer Table 510ft. <br />n. <br />Character of soil to a depth of 3 fee+:. Sand E] Gravel 0 Sandy Loam E] Clay Loam [] Clay Ej Adobe j �ardp,, [I <br />Previous Application Made: Yes E] No t,---qew Construction.: Yes El No <br />TYPE OF INSTALLATION AND SPECIFICATIONS: <br />(No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br />Septi n k:, Distance from nearest well ----------------- Distance from foundat;on ------------------- Material.-- <br />Noof compartments� ------- �'7� ---------- Size---- <br />--------- -------- -------- Liquid depfh ------------------------- Cap6cify --- ------------------- <br />f <br />isposal �Fiield: Distance from neare'st we -11--) ----- �,_D)rstance- rom foundafion --------------- 1 ---- Distance to nearest I lot line.__."__..___. ---- <br />Nu mber of lines ------------------------------ LengtN`�_of each line ---•------ L -------------- 1___Widfh of trench ----- ---------- ------------- <br />ek % <br />f filter rnaterial--".,-,. 1 ---Total length--:-------------- __ -------------------- <br />Type of ---- -- -------- --'--Depth of filter maferial ---------- ..... . <br />J� <br />Seepage"Pit: Dis-fa'nc'e""fo—near—esf'_yel�;�0-- �_ - ------- �Nnce from fo6l�Ofion- <br />------ /01- ..Distance to nearest�lof line____,6 -------- <br />Uj__— Number of pits ----- I -- ------------ Lining mafenal_& �_AKSize: Diamefer___,33_.'��­ De'p6_'&lt-­%;��5� <br />Cesspool: Distance from -nearest well ----------------- Distance from foundation --- ---------- 3 ----.Lining m6terial ------- 11 ----------------------------- <br />❑ Siz6: Diameter ----------------- ------- -------- -"Depth------ -- I,_:--------. --------------------- I ---- Liquid Capacity- ---------------------- gals. <br />--------- <br />Privy: Disfanc , b from nearest well_: ------------- ; ----- --[- --------- --Di,t,'nc from nearest building -z--------- ----------------- - - -- - <br />1. 11 14 - <br />Distance to reafesfllot-line -- ----------------------- - — --------------------------------------------- ---------------------------- <br />Remodeling and/or repairing (clesci­66) ------- ---------------- .......... <br />J -------------------- ----------------------- ---------- -------------------------- ; -------------------- <br />............................... I ------ .: ------------------------------------------------------------------------------- ----------------------------------------------------------------------- -------------- ---------- <br />----------- ------------ I ----­---------------- ------------ ........ -------_------_---------- - --- I . .......... -------------------------------------------------- ----- --- ----------------------------------------- <br />---------- <br />---------------------------------------------- <br />---------- -------- ---------------------------------------------------------------------------- ------------------------- 7 ---------------------------- -------------------------------------------------------------------- <br />1-hereby certify the+ I have prepared -this application and that the work will-be-done'in accordance with San -Joaquin . County <br />ordinances, S" laws' nd rand jr gulatio s i n of fh San Joaquin Local Health District. <br />m, <br />- ---------------- -7 - ------ ---------- t0:ne7—aWdVo Contractor) <br />(Signe --- ---- ----- -- ----------- ----------------- F__ <br />--------------------------- <br />By: ------- - ------ ------- --------------------------------------------------- (Title) ---- _&1r <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 />< .010.�. <br />REVIEWEDBY -------------- ---------------------------------- DATE ----------- - ------- ------------------ ...... <br />BUILDINGPERMIT ISSUED--------------------- ------------------------------------------ DATE------------------ ----- ------------------ <br />Alterations and/or recommendations: ------ --•-------•---------------------------------------------•-------------------------- ................................ <br />---------------------------------- <br />-------------- I ------------------------------------- I ---------------------------------- ------ -------------------------------- I ----------------------------------------------------------.....-•----•-------••-------- <br />---- ---------------------------- --------------------------------------- ------------------------------------- ------------------ ------------------------------------ ­ .................. ---------------------------­ <br />----------------- ----------------••------------------------------------------ ------------------------------ ---------- ------------------------------------------ ---------------­------­- -------------------------- <br />----------------------- -------------- -------------- ­ ------- ---------------------------------------- I -------- ----------- -------------- ....... -------- --------------------- <br />------------------------------- <br />FINAL - INSPECTION BY:�� - ---------------------- Date___/�_/__2 ................. 111' <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 Manteca, California Tracy, California <br />ES -9-2M � I Revised W-2100 <br />