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J <br /> APPLICATION FOR SANITATION PERMIT Permit No. ..............L- <br /> in Duplicate)(Complete P ) � a Qate 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. /1 <br /> JOB ADDRESS AND LOCATION-----✓ ,v3--- _. - ------------------- ----------- <br /> Owner's Name-------� ---- Phone -,�� Z <br /> Address--------- .(------ -------- --- -- --- ------ <br /> zz 44 <br /> Contractor's Name----- ------ ----- Phone--� Q . <br /> Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court E] Motel E] Other ❑ <br /> Number of living units: __/-_ Number of bedrooms __ __Number of baths /.__ Lot size ---_____�_-_X-_l1Wd___--------------------- <br /> t �/ <br /> Water Supply: Public system [Community system El Private ❑; Depth to Water Table _7_�_ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy,Loam [❑ Clay Loam ❑ Clay ❑ Adobe ET`_H'­ardpan ❑ <br /> Previous Application Made: Yes ❑ No [!3 �New Construction: Yes F<No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> i <br /> Septic T,k: Distance from nearest well _Distance -from foundation___ld--------- <br /> Materials.___.__�Capacity <br /> [� No. of compartments Size SLL:___ y4_rY,�__Liquid de th____ _?� —P 7 q I? - -- <br /> Disposal Field: Distance from nearest well-7} ?�--Distance from foundation_____- ____.__Distance to nearest lot line__._._....Y�. <br /> Number of lines_._.____l.............___ - Length of each line_____7s:�_---- i _.Width of trench______2_ _�- <br /> Type of filter material__Sc_l? _.Depth of filter.material[_./ _________Total <br /> length________7_`S_ ----------------------- <br /> See <br /> ______________________See Distance to nearest well- /7 from fou dation____ _ ---------- to nearest lot line-----S_________ <br /> Number of pits------/-------------Lining material-L&Size: <br /> Diameter-----176_ -----Depth----- -25--------------- ---- <br /> Cesspool: Distance from nearest well_---------------Distance from;foundation-----------_------ Lining material-------------------------------------- <br /> 0 Size: Diameter--------------------------------------Depth- *------------------------.:--------(,:-----------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well---------------------------------- --------------Distance from nearest building------------------------------ -----___-_. <br /> ❑ Distance to nearest lot line---------------------------------------------------------------------- ----------------------------------------------------------------------- <br /> rf � <br /> Remodelingand/or repairing (describe}--------------- ------------------------- ------------------------------••--: -----------------------••-----------•------••------------------------ <br /> 1 <br /> ------------------••----------------------------------------------------------------------------------------------•----------------------•-•--------------------------------------------------------------------------------- <br /> -----------------------------•-------- -------------------------•-----------------------------------------•--•-------------- ---------------------------- --------------------------•-•-------- ---•------------------- <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 regulations of the San Joaquin Local Health District. <br /> (Signed)....... =' -- / �'��*syst� in <br /> --------------------------- -- -(OwAr and/or Contractor. <br /> By:---------------- --------A -- - -- ------------------------------------------------------(Title)- � : _, <br /> (Plot plan, showing size of lot, location relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ------- } / --'------ DATE-- ---------••-------------- <br /> REVIEWED BY-------------------------------------------------- ------------------------------- --------------------------- DATE-------------------------------- ---- <br /> ---------------------- <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------------•-------------------------------------- DATE-------------------------------------------------------------- <br /> Alterationsand/or recommendations:--------------------------------------------------•--•---------------------------------------------------------------------------.----------------------------- <br /> -------------------------------------------------------------------- ------...------- --------------------------•--------------------------- --------------------•-------------------•-------------•--•--------------------- <br /> --------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------•------------------------•----------•--------••-- <br /> ------------------------------ --------- - -------------------------------•----------- ------------------------------------------------------- --------------------------------------------------------------------------- <br /> 1 /J� s <br /> FINAL INSPECTION BY-------------- /-------- --- 1 ----- Date--------------3---- --------`c}� -------------------------- <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 W-2100 <br />