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1y1fi' 7/f� 9// - �1 /:�� / 7 <br /> `y APPLICATION FOR SANITATION PERMIT Permit No. ___ �.............. <br /> (Complete in Duplicate) <br /> Date Issued <br /> Application 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 Coun y Ordinance No. 549. <br /> JOB ADDRESS AND LOCATIO - *f - - ----------------- --------------------- -------------------------•_.----- <br /> Owner's Name------------- --- -- -- -- -- ,------.:'-- - -------------------------------------------------------- Phone-------------------• --- -- <br /> Address--------- <br /> Contractors Name--•-_... •----- -- Tf.�� 1 ----------- �"� Phone <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [❑ Motel ❑ Other ❑ 7� Y/� <br /> Number of living units: ---/__ umber of bedrooms. Number of baths ---e. Lot size ___ ___ ___,f_______ ___ _____-----------_______________ <br /> Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table _ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 4�1�Hardpan ❑ <br /> Previous Application Made: Yes ❑ No [ New Construction: Yes R+ o ❑ PHA/VA: Yes A--Ilo ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> SepticT� Distance from nearest well-'-- '--_-_Distance from foundation_--I�_-__-Material_____�� -- - - ------------- <br /> '~ __DNo. of compartments------9---------------Size_ __X_1 ___Liquid depth_ __ .__._____Capacity__. s€------------ <br /> Disposal <br /> is osal Field: Distance from nearest well--.---- ------Distance from foundation.___.___.Distance to nearest lot line-_-, ......... <br /> 'A Number of lines_______________ ___ �-ength of each line------- _ �` <br /> � �lf------Width of trench.- -- --!�-�'-�- --- ------------ <br /> --- <br /> ---- --- <br /> Type of filter material- / /-Depth of filter material__ , ff�// Total length____ c __ ___.._____.__r <br /> Seepage it: Distance to nearest well-------____�--__Distance from oun�tion_-_-�Z'-_ ___.Distance to nearest lot line__.•��_.7___.- I <br /> k Number of pits-------- -----------Lining material-/s Diameter_,,, .._.__..___Depth________-________________________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_-___----._.--.----_._-_---__-------- <br /> ❑ Size: Diameter---------------- --------.- -----------De th-----------------------------------------------------Liuid Capacity -•-------•---------------gals. \\ I <br /> . <br /> Privy: Ristance from nearest well ----.__--------------------------- --------Distance from nearest building__-_-____---.____-.--__---_.-__--.__-_. (� <br /> ❑ Distance to nearest lot line.----------------------------------------------------------------------------- ----------------------------------------------------------- <br /> Remodeling and/or repairing [describe] al te. <br /> ------------- ----------------------------------------------------------------------------------------=---•------------------------------- -----------------------------------------------------•---•----------------•------- <br /> ------------------------------------------------------------------------------------------•---------------------------------------------------------------------------------- ----------------------7-------- -------- <br /> x <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 laws, and rules and regulation of the San Joaquin Local Health District. <br /> {Signed}.. "---------------------- <br /> -----------(q.� LF1dr Contractor] <br /> By:--------------------------------- ------------ (Title]Gf� � s - " <br /> {Plot plan, showing size of to cation of system in relation to wells, buildings, etc., can be placed on reverse e). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- •------ -- -------- ----------------------------------------------------------------------- DATE------------- `5 <br /> REVIEWEDBY--------------------------------- 4P----------------------------------------------------------------------- DATE-------------/A------------- <br /> BUILDING PERMIT ISSUED------------- ------ t - DATE----------A----------------------------------------------- <br /> Alterations and/or recommendations:-------- <br /> ----------------------------------------------•----------------------------------------------------------•----------------------------------.------.•------------------------------------------------------- <br /> ---------- ----------- .-------- ' r _-e-4------ ---------- ....... ��✓_�'....- <br /> ---------------------------------------------`- ---------------- <br /> .� .fe3_ 7ye<----------------------------------------- <br /> -------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------ --------------------- ---------------- --- ----------------------•--------------- -------------------------------------­­------- <br /> FINAL INSPECTION BY---------------- • e - 4,. Date `fl = <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 1.57 FY-CO- <br />