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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued - --- - ---- <br /> '? <br /> Applica4ion is hereby made to the San Joaquin Local Health Dist rict.for a permif to construct and install the work herein described. <br /> This app I ication is made in compliance with Cou ty Ordinance No. 549. <br /> Oc - ---- -- -------- <br /> &B V ----------------- <br /> �G61DRE-5-'AND- -�AT 110 N --------W__1 <br /> J <br /> --------------------------------- --- .... <br /> -44te-74 , - - - , -_ - --- . I <br /> Owner's Name---_- --—- --------- 0 e------------------- <br /> --k----------- ------------ <br /> Address-------------------------q-:5*b------E__ ------ ----------------------------------------I-------------------------- <br /> Contrcfor's Name-----------------­----------- ---------------------------------------------------------- -- ----------------------------- Phone----------------------------- <br /> Installation will serve: Residence Apa ent House El Commercial E] Trailer Court E] - Motel E] Other 0 <br /> Number of living units: --_I__-- Number of bedrooms --1---- Number of baths Lot size ----------[I �----------------------- <br /> Water Supply: Public system 0 Community system El PrivateDepth to Water Table---_ tt. <br /> Character of soil to a depth of 3 feet: Sand F Gravel n y L, <br /> I Sand am E] Clay Loam [] Clay E] Adobe Hardpan 0 <br /> Previous Application Made: Yes 0 No 9 Nev l.&, ion: Yes 1A No 0 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public s er is available within 200 fee _-N <br /> Septi c Tank: Distance from nearest well-----70----Distance from found tion_____(_-- Mater ---------- -- ---- -------- <br /> No. of compartments------ Size--- depth ------------- <br /> A <br /> Disposal Field: Distance from nearest w II_ Distance from foundation___A_0__s____Disfance to nearest lot 14_�---k�.. -------- <br /> Number of lines-------------I ----7-0-------i <br /> W tT... Length of each line------ --.-.Width of trench. ;Z--- ----------------- <br /> /L4N tw 1 141 <br /> Typeof filter material---------)1A)tADepth of filter material__.__.I}_ =_._Total length---------1-0--------------------------- <br /> p <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> El Number of pits----------------------Lining material----------------------.Size-Size- Diameter------- ---------------Depth---------------------------------GB <br /> Cesspool: Distance from nearest well-----------------Distance from foundation___.'-.-_.-_---.--- Lining material_-_____-____---.- -------.--__-_-_._. <br />' ❑r <br /> aterial------------------------------------- <br /> r Size: Diameter---------'-----% --1------------ -------------_= - -- — � --____-==Liquid .g. <br /> ------ --------- -eapacify_:_;T <br /> Privy: Distance from nearest well_--------- ------------------------------------Distance from nearest building___________-__.____________________- 1" <br /> ❑, <br /> uilding---7-------------------------------------- <br /> F-1, Distance to nearest lot line----------------------------------------------- ---------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing [describe):------`;4 ':� - �- ----------------------------hLX,1(Al A <br /> ------------ <br /> --------------------------------------------------------------------------------------------------------------------------------------I------rT-----------I- <br /> ------------------------------------------------------------------- <br /> --------------- --------------------------------------------------------­---------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------I-----------I---------------------------------------------------------------------------------I-- ------------------------I----------------------------- ------- <br /> I hereby certify that I have prepared This application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State la* , and rules and regulations;/of'f he Sah Joaquin(Local Health District-. <br /> (Signed)-----------C115 -------- --------------------------------------------------(Owner and/or Contractor) <br /> BY=-------------------------------------------------:---------------------------------------------------------------------------------(rifle)-------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of-system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPAOPENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------------------- ------ -------------------------------- DATE--- ------------------------- <br /> REVIEWEDBY---------------------------------------------------------- - __V111flv - .__ I-------------------------------------- DATE--- -------------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------- ---------------------------------------------- DATE------1)--------------------------------------------------- <br /> Alterationsand/or recommendations------------------------- --------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------- - --- --------- ------------------------------------------------------------------------------------------------------ <br /> I 1��. A*- <br /> ------------------------------------------- ----------------7- ------ ---)------------------- -----------------------I---------------------------------------------------------------------- <br /> I( -- ----le <br /> ------------------------------------------- I----------------- ---------------------------------------------------------------------------------- -------------------------- ----------------------------------------------- <br /> - ------------------------------------------------------- ---- -------------- ------------------------- ------------------------------------------------------------------------------------ <br /> '2- -- - <br /> FINAL INSPECTION BY...-------- Date--- ---------4-------I-------- ------- <br /> --------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Sfockfon, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />