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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> - Date Issued __-.. <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 LOCATION -'1 C. `i--------------------------------------------------- <br /> --------- - +----�/�--,'-r t �`1 Y�1 R - <br /> Owner's Name 1_ <br /> -------- -----------As--L�>--ti'1- ---- --- -------- -------- Phone-------------- <br /> Address-------------------------------- ` 2 O Y r <br /> ---------------------------------------------------------------- <br /> Contractor's Name-------- �-�' I t------•----------------------------------------I------------------------ ----------------•--------------- Phone----------------------------------- <br /> Insfalla+ion will serve: Residence Rr<partmerif House ❑ Commercial (] Trailer Court ❑ otel ❑ Other ❑ <br /> Number of living units. 1_-_ Number of bedrooms -.2- Number of baths __f__ Lot size Y_ ' t e-k_ 0'_ <br /> Water Supply: Public system ❑ Community system ❑ Private �epth to Water Tablex'---• ft. <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: Yes [] No ©'— C1%6 ;Iee <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if pu iic sewer is available within 200 feet.) <br /> Se f' T k: Distance from nearest well---- ---------Distan f}r�o fyoun tion-----�__��-__----Maf ri I_____�fee-11v -L�-G�„ <br /> No. of compartments_.__--____ate___►' __Size__ ,ll /�_._. _Liquid depth--____�-- ..__------Capacity_..f "t� <br /> Disposal Field: Distance from nearest w I------------------ <br /> ____ YDistance from foundation-----I__7~_Distance to nearest lot Ii <br /> Number of lines----------- ,- ---�------ -Length of each line------I'/-Q __ Width of trench_._-_�._.5 <br /> Type of filter material--�__ __-�____Depth of filter material___._ _ - _Total length-------11_d-__.-_________--____-- <br /> Seepage Pit; Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-------.-_______ D, <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---------------_ <br /> ----------------- <br /> Cesspool• Distance from nearest well-----------------Distance from foundatidn--------------------Lining material-------------------------------------- <br /> Size:-Diameter------------------------ <br /> ____--________----.__Size:_Diameter----------------•--------•-----------Depth-__----- - :.--- -------•--------------------Liquid Capacity.. -----gals.. —� <br /> Privy: Disfance from nearest well__________________ ____-___-----------_________Distance from nearest building______--______._--_______- <br /> El <br /> Distance to nearest lot line---------------------------- ----------------------------------------- <br /> Remo el ng and/or repairing (describe):__-______ _ ef � -6 V -P � <br /> ' ::------------ <br /> r� tiro ! - �'• ! 1/t/' <br /> ----------- <br /> - ' a _ ------------ - ------ <br /> r r ----------. ¢ = = <br /> --- ------------------------- - <br /> I hereby certify that 1 have pre ared-Als application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, <br /> and rules/and regulations of the San Joaquin Local Health District. <br /> (Signed)-- �� -f7--—,-t _+f. —.r� <br /> ---------------------------------------------------------------(Owner and/or Contractor) <br /> By:----------------------------••--------------------------•---•----------------------------------------------------------------------(Title)-------------------------------------------- ------------------- <br /> (Piot 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 /> REVIEWEDBY ------------------------------------------------=-------------------------------------------- DATE------------------ <br /> --- -- ---------•---- <br /> BUILDING PERMIT ISSUED----•---------------------------------------------------------------------------- ------ DATE. <br /> ------------------------------------ <br /> Alterations and/or recommendations:-------------- ---------------------------------------- <br /> ----------- --------------------------------------------------------------•------------------------------------------------------------•--------•-----------•----•-------- <br /> -- ----------------------------------------------- ---------------- --------------------------------------- -•------------------------------- ---------•----- ------------ <br /> FINAL INSPECTION BY:------------------------------ <br /> ------ ----------•---------- - Date------------------ <br /> ---------------- --------------------•------------- <br /> _SAN JOAQ'"U�I`NN 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-4-2M ; Revised W-2100 - <br />