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f V// <br /> ' APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> s ,w .. - Date Issue J'� <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work here n described. <br /> Th Fs application is made in compliance with County Ordinance No.-549. <br /> JOB ADDRESS AND LOCATION - -lG---- -- 0 '. ........... <br /> Owner's Name------------ <br /> --------a-------- -----• ---- ­ -•------- --------=------------------------------- Pho <br /> Address------- ......... F <br /> Contractor's Name----------------------___ <br /> i 1 1 ---------=------------------- Ph - - <br /> Installation will serve: :Residence k Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ y <br /> Number of living units: ----I" Number of bedrooms __�j.__- Number of baths _ � ! - y <br /> g f� Lot size ------------------ <br /> Wafer-Supply: Public'system'5,Community system ❑ -Private ❑ Depth to Water Table 0_/Vft. <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 jk New Construction: Yes ❑ No ❑� l�, <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: / <br /> (No septic tankorcesspool permitted if public sewer is available within 200 feet.) <br /> tic T Distance from nearest well________________Distance from foundation--------------------Material <br /> No. of compartments---- ---------------- ----Size---------------•--- ------------Liquid depth-------------- -----------Capacity----- ----------------- <br /> D o Distance from nearest well _________--------Distance from foundation---._____------------Distance to nearest lot line_______.______... <br /> Number oftlines__..-` Length of each line Width of trench---------------•-•------------- �1} <br /> Type of filter material-------------------------Depth of filter material----------.------------Total length-'.. . 4 S ------ <br /> Seepage Pit: Dis#ante to 'nearest well_ Q -�4_____Distance fro fo datlOn__ ________.Distance- to nearest lot line__. <br /> �g�► r� / <br /> x Number of'pits----I---------------- <br /> Lining material__�.Size: Diameter.-taJ +- -fir--- Depth a _a� <br /> ------------------- <br /> Cesspool: Distance,,f-brn nearest well_________________Distance from foundation.____._...._-:_____.Lining material---.__________._._._______ <br /> , , ----- ---- <br /> 0 . Size: Diameter----------------------- -- ----------Depth-----------------`-------------- ----------- �----Liquid _ <br /> _ <br /> Capacity---------------------- gals. <br /> Privy: Distance from nearest well--------------------------------------------- from nearest building_._______..___-______.______ <br /> - % �•T <br /> ❑ Distance to nearest lot line_ _ = ------------------------------- -----------=------------------------------------------- <br /> r <br /> Remodeling and/or repairing (describe)----------------------------------------- -------------------- <br /> ------------------------------------- <br /> ----...-•--------------_- ---- <br /> ---------••------------------------------ <br /> -------- I-------------------------------•--------------------------------------..--------•----------•--•--------------------...------------------------------- <br /> -------------------- <br /> -------------------------------- -----• -------• _ <br /> ------------------- <br /> I`hereby ce if tha have pr pared t is application and-that the work will-be done in accordance with San Joaquin County <br /> ordinances, State s riles regul ions of the San Joaquin Local Health District, <br /> (Signed)--------------- - ----- -- ----- .� ; <br /> 4.itwells'-buil <br /> I o a t I <br /> ---- ... A n r c <br /> t <br /> By: -- -- ---- ---=•-- Title <br /> { -P.t ---------- -------- <br /> (Plot plan, showing size of lot, location of system in:rela - gs, etc., can be placed on reverse side). <br /> FOR-DEPARTMENT USE-ONLY + �f <br /> APPLICATIONACCEPTED BY--- --- -- - -- - -- �.•- - -�: a._ __6 <br /> DATE_ 3 _. __6- ---------------------- <br /> REVIEWED BY �------------------------=------------------- ------ Q <br /> DATE ----••--------------•---•----- <br /> BUILDINGPERMIT ISSUED ------------------ - -------------------------------------------------------- -------._ DATE------------------------ <br /> -------------- <br /> Alterations and/or-recommendations_----------------------------_ <br /> -------------------- <br /> ----------.—__ •--------- <br /> ------------- <br /> ------------------------------------------------------------•--- -------------------- ---------- --------------------------•-------------...._._..--•--------- :. <br /> -----••-----------------•-------•-•-------- <br /> -------•----------------------------------------I-------------------------------------------- ----------------------------------------------------------•------•----------------------- - <br /> __... _______________ <br /> ____ ________ - <br /> - _ _____________________ i_____-.__.______.--______________________.__.,-__-_________-_-_______.____....________-_.______...� -------------------- ______..._-_- <br /> ------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------- <br /> FINAL INSPECTION BY-----=---------- -------- ---------------------- Date S" <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> - ti Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES 9-2M Revised W-2100 I <br /> x <br />