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�.• APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate)' S <br /> _ Date IssLd - <br /> ............ <br /> Applicarion is hereby made to the San Joaquin Local Health District for a permit to construct and install the wordescribed. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION------ 7-- '------- - - ---------------------------------------- <br /> Owner's <br /> ---- ---------Owner's Name--- ---------- - ------------ .�G�l _ -----* ------------ --- Phone--- -- -----•--- <br /> Address <br /> � - "" <br /> ----------- --. -------------------------------•--••------------------------------ <br /> Contractor's Name------ 1 ------ � `' ------ --------------------------------------:------ Phone'4"d-r�- Z r'- <br /> Installation will serve: Residence ❑ Apartm6nt House ❑ Commercial ❑o-Trailer Court ❑ Motel ❑ Other <br /> Number of living units: _ __ Number ofbedroorris Number of baths'_{ Lot;size ____ Q4__' _ C t_______________________ <br /> -- <br /> Water Supply: Public system ❑",. Community}system ❑" Private jo" Depth'to Water able -elA ft. ` <br /> Character of soil to a depth of 3 feet Sand.❑ Gravel 0 Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe's Hardpan ❑ <br /> Previous Application Made: Yes ❑ No'X <br /> New Construction: Yes �' No E]TYPE OF INSTALLATION AND SPE IFI//CATIONS: " I- .1 01 , <br /> (Nom <br /> .septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> c�Ta k: Mstance from nearest well___ . ----------Distance•from'foundation------------_-------Material______-_----__-_________.__________-__.______- <br /> No. of compartments--__-.-..,;,_–n�-_: 4- Size---------------- -------------Liquid_depth--------------------------Capacity-_.-------------------- <br /> eld: Distance from nea,e st welL._S~d.�'_.:Distance fro..fioundation__ 4_w__`_:Distance to nearest lot line----_��_ �._.. <br /> Number of lines----.---- -___-�j-------n-_�Length�of,each line---_---�_47 a- ._.Width of trench-----'- �'----------------- <br /> Type of filter. rnate�ial------ _0q_t-.- -Depth of fiiter material____Ls _�_, __.__Total length-----/a_a----­------------------- <br /> 4 eep Pit: Distance to nearest well--------------- ----Distance from foundation____`___'_.__.-..Distance to nearest lot line______._________ <br /> Number of pits-------------------=--Lining material---------------- :__.Size: Diameter------------------------Depth--------_------------------------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------_---_---------Lining material------------------------ ___________- <br /> ❑ Size: Diameter ----------------------zDepth_---------------------------------- ------.Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well___________________________--------------#_"__Distance from nearest building----------------------------------------- <br /> El Distance to nearest. lot Gne------------------------------- -'- - <br /> 1 <br /> Remodeling and/or repairing (describe)------------------------------------------ - ---••••------------------•---------------------------...-------------------------------------------- <br /> { <br /> --------------------------------------- ---- ----------- ----------------•------•-------------------- <br /> -------------------------------- <br /> ------------------ ----- - ------------------------------•---------------•------------------------------------------------ <br /> --------------- <br /> I hereby certify that I have prepared this application and than the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District.. <br /> (Signed)----- �.�[ e" ._ --" ---- -------------------- . .. _______ (O er and/or Contractor) <br /> By:---•-------• �'f✓ Ti+le--- <br /> (Plot plan, showing size of lot, location of system X"relation to wells, buildings, etc., can be placed on'reverse' side). <br /> FORAEPARTMENT USE ONLY " <br /> APPLICATION ACCEPTED BY - - ---------- -------------- -------------------------- ---------- DATE " .t. � <br /> i� f ��------- <br /> REVIEWEDBY--------------------------------------- ---- ----- --------------------- ------------------------------------------- DATE-------------------------------•---- ----------------------- <br /> BUILDING PERMIT ISSUED----------------------------- = DATE <br /> - ------------ <br /> Alterations and/or recommendations:--`------ ---------------------------------------------------------------------------------------- --•------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------- ...............-------------------- <br /> ---------------------------------------:---------------------------------- ------------------------ -----------------------------------------------------$--------------------------•---------------------------------------- <br /> ------------------------- --------------------------------------------•----------------------------------------------------------------------------------------------•------------------------------------------------•---- <br /> FINAL INSPECTION _ = .._Date <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-4-21v1-��Re�;se -2100 �-. 1 <br />