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APPLICATION FOR SANITATION PERMIT Permit No,11171-Y-2 <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 County Ordinance No. 549. <br /> JOB ADDRESS AND LOC fON 1/'_1!57e4_47- -- � " `� ------------------------------------------- -----------------=------------------------------ <br /> Owner's Name----------- ------- .. Phone------------------- <br /> Address-------------------------- ` <br /> Contractor's Name------------ •--- -----•- -------•----------------------------------------------------------------------------------- Phone----•__------------------------.... <br /> Installation will serve: Residence &4---p—artment House C] Commercial <br /> Commercial E] Trailer Court E] Motel E] Other E]Number of living units: __1___ Number of bedrooms __J----- Number of baths I__-_ Lot size _________________ <br /> Water Supply: Public system ❑ Community system ❑ Private epth to Water Table -Ve ft. <br /> Character of soil to a depth of 3 feet:` Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe EA I- zn-❑ <br /> Previous Application Made: Yes ❑ No ew Construction: Yes 5a ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: awl) <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Se Distance from nearest well___ __ O...Distance from foundation___-IZ--____-_.Mat ial______-___ <br /> Septic Tank: <br /> p No. of compartments_--____�---______.__Size----- _K__�_ 4? ___Liquid depth-----_ '__________CapaciI Disposal Field: Distance from nearest we!l___ __ __Distance from foundation/___ _p ___-Distance to nearest lot�line/,-i,___ _ _ <br /> Number of lines____________ ____________ _____ Length of,each line_______--6 Q_s,-[___________-Width of trench_.---------p 7 <br /> ----------------- <br /> Type of filter material- - _ __ _______Depth of filter material__-- t_' ----_-Total length_____________�?.__. ._____._____________ <br /> Seepage 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 /> El Size: Diameter------------------------ ------------Depth----------------------------- -- -----Liquid Capacity----------------------------gals. <br /> Y Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____________________________-_.______-__. <br /> ❑ Distance to nearest lot line---- --------- ---------------------------------------------------------------------------------------------------- --------------- <br /> i <br /> Remodeling and/or repairing (describe)------ ----------------------------- -------------­---------------•------------------------------------------------------------•-••-----•-•---•---- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------.----------------------------------------------------- ------------ <br /> ---------••----------- -----------------------------------------,---------••----•---------------------•---•------------------------------•--------------• ---------------------------------------------------------•------- 1 <br /> t <br /> hereby certif th t I'have repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State ,,And rul�a40 regu ations of the San Joaquin Local Health District. <br /> ----------- <br /> (Signed) „,-...�------------- ----------------- ------------------------------------------- Owner and/or Contractor <br /> - ---- - <br /> gY= ------------ -- --------------------------------------------------------------------- (Title) <br /> ----------------------- <br /> (Plot plan, showing size of lot, locatj of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------------------- ------- --- -- --------------------------------------------------------- DATE---------- r <br /> REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------------- DATE------------------------------------------------------------ <br /> BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------- ------------------------------------------------- - <br /> Alteraiiionsand/or recommendations:------------------------------------------------------------ -------------------------------------------------------------------------------------------- - <br /> = `" ------ ----------------- <br /> ------ . . <br /> ----------------------------------`� i ----------- `•r.`----��- "----------�5. ... f�f <br /> f fL ",,.' i r ff %y.L�/��� ��yV��'-fi�J��+�. <br /> FINAL INSPECTION BY:---------- - ------ Date---------- ,/..- Gl s'--------------------------------------- <br /> i 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 8-51 Revised W-2100 <br />