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a <br /> APPLICATION FOR SANITATION PERMIT Permit No. --- .-_- <br /> (Complete in Duplicate) ul, q <br /> Date Issued ------ l <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 /> JOBADDRESS AND LOC N----------cf-11----7_5----------------------------- ----------- ---------- - ----- ----------------------- ----- <br /> a / <br /> Owner's Name--------------- ------------ ----- ----------------- ?hon ----- <br /> Address------------------------- ----- ---- ----------------- .--------------------------------•------•--------------------------•--------,-[--/��----- --1�-lft-------- <br /> Contractors Name------------------------------ ------r --•------------------- - Ph e./7 _ r�_ Q <br /> Installafion will serve: (Residence 0"!Apa ment House El Commercial E] Trailer Court E] Motel C] Other ❑ <br /> Number of living units: -1----- Number of bedrooms _1_-'Number of baths __/.--- Lot size .....-b- _K_f_ ---------------------- <br /> Water Supply: Public ysystem`A Community'system ❑ Private <br /> '0'. Depth to Water Table __ `__-'ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[X Hardpan ❑ <br /> Previous Application Made: Yes ❑ No'o New Consfr ction:=Yes ❑ No <br /> DQ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: f <br /> (No septic tank;or cesspool perrnifted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance-from nearest well-----__._-_----Distance from foundation--------------------Material-------------------------------------------------- <br /> ❑eXiS11V No. of compartments--------r-----=---------Size--------------------------------Liquid depth--------=-----------------Capacity----•------------------ , <br /> 4 <br /> ❑Disposal FSe G la 'neare'st well-------------------pranon . -.---Distance to nearest loft line----------------- <br /> Numberc,nesengfh of e hIne ----------------Width <br /> of trench----.---------------------___--_-- <br /> t Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ <br /> Seepage Pit: Distance to nearest well__dn --'Distance from fo�w9n" anon_ _-__.-__.Di ice to nearest lot line----------------- <br /> Seepage <br /> of pits--4`!'s�:--.--Lining materiali�2JL4t 'Size: Diameter---3-----------------Depth--.,� --_- ' <br /> --------------- <br /> Cesspool: Distance from nearest well----"----- Distance from foundation--________________.Lining material_------------_-------_-----_ _---_-. <br /> ❑ Size: Diameter = Depth ------------------ <br /> Privy: <br /> == `=z ,Liquid Capacity------------------------ gals. <br /> - _ <br /> Privy: Distance from nearest well-_._i---------------------------------- ------�_---Distance from nearest building------------------------------------------- <br /> 4-- <br /> . .. <br /> Distance to nearesfiElot line---- ------ <br /> fi t � <br /> a <br /> Remodeling and/or repairing (describe)--------------- - ------- <br /> = ------------=-------------------------------------- ---------------- --------------- -- - <br /> t ---------------------•------- <br /> -• - -- <br /> 4 { ----•------------------------ -------- <br /> ---------- --------------------------- --------------------------- <br /> ---•----------------- •----- <br /> I'hereby cerfify.fhalndtjles <br /> pared this a�plicationYand +hat the work will be done in accordance with San Joaquin County <br /> ordinances, State laws; ad regulations..of th an Joaquin Local Health District. t <br /> C Contractor) <br /> (Signed)------... ------- -- <br /> -' - ------:--- {Owner and/or + ) <br /> fes' ---ITitle- -- ------ = <br /> gY� + ----------------------------------- <br /> i(Plot plan, showing size of lot, location of sys+ n relafion to wells, buildi gs, etc., can be plat on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY-------- -- - ------- ------------------------•--------------------- DATE----- -------------- --------------------------------- <br /> REVIEWEDBY------------- ---------- --- ------------•---------------------------------------- DATE- t___�PERMIT ISSUED------------------------------ <br /> --- -------------------------------------------------------- DATE------------------ Z` ---------- <br /> Alterations and/or.recommendations----------------- -----------------...'----------------------------•-------------- .-. vim.... ...... <br /> ------------------------------ - <br /> ------ ----------------- --------------------------••----------------------------------------------------------------------- <br /> -------------- •----------------------------------------------------------------------------------------------------------------•----------------- <br /> ---------------------------------------------------------=----------------------------------------------- ------------------- <br /> ------------------------- <br /> -'---------------- <br /> --- ---------------=----------------------- -- --------------------- ------- - --------- <br /> •-------- ---- <br /> l �! � D <br /> FINAL l SPECTION-BY:. ---- ------- Date-_ -------t, '�,--_-----�----------------------------- --------------- <br /> ------ •--- <br /> � �i 'v ' AA <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 ; Revised W-2140 <br />