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i� <br /> t�\4 APPLICATION FOR SANITATION PERMIT Permit No. ..�d__Tl....... <br /> (Complete in Duplicate) //S <br /> Date Issued ____�_/..._ <br /> Applila}ion 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 /> I! J <br /> JOBADDRESS AND LOCATION---------- 1 �_?..----- .f1 Q -----------------------•-----•----------------------------------------------------------- <br /> Owne''s (f-------Name-------- ------------------ - <br /> --------------- ----------------------------------------- Phone------------------------------------ <br /> I d ,I <br /> Address.-------- � ------------------------------------------------•-•-------------------------------------------------..---------__---------- <br /> n / ti <br /> Contractor's Name-----1-�-'--�'..� -- -- -- -- --�- --------------------------------------------------- Phone./Yl.2."-(�-----c�-�_�_] <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> ° Number of living units: ___1__ Number of bedrooms ___..Number of baths __/___ Lot size __. a_-_aC____I_a2.o__________________________ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. 1 <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA Hardpan ❑ i <br /> Previous Application Made: Yes ❑ No New Construction: Yes 0 No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> � r <br /> Septic Tank: Distance from nearesr well------�-----Distance from foundation----1_ -----------Material -__C•e------------------------------------- <br /> No. <br /> _No. of compartments----------------------Size---* /---X-- ji------Liquid depth--------------------------Capacity------900 i <br /> Disposal Field: Distance from nearest well--" ______.._Distance from foundation----f� ______Distance to nearest lot lire____ <br /> ® Number of lines------------ ___T---------------Length of each line---------,10__-__-` jjWidth of trench—.2.4 <br /> ! <br /> Type of filter material_-_-l� +±�___R.v� Depth of filter matenal____'t'�___ Total length--------1-0_I___________________________ <br /> Seepage Pit: Distance to nearest well-------- _�- <br /> -________Distance from foundation____4 •_-___.Dista ncte to nearest lot line-,---f0__.___- <br /> ® Number of pits-------I-------------Lining material__ G__ -t5ize: Diameter-___._ ___--------Depth-----A�r_________________ 4\ <br /> CessP,00l: Distance from nearest we1L________________Distance from foundation--------------------Lining material _____.-------------.------,___._____. <br /> M <br /> ❑ Size: Diameter--------------------------------------Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. 11 <br /> Privy:I Distance from nearest well-------------------------------------------------Distance from nearest building------------------------ ._-------------. V, <br /> ❑ Distance to nearest lot line--------------------------------------------- ----------------------------------------------------------------- --------------- - <br /> Rem�deling and/or repairing (describe):----------------------------------------------------------------- ------------••----•------------------------------------------------------------ <br /> =-------------••-•-----------------------------------------------••--••-----------------------•-•----------•---------------------••------•---•-•---------- ------------------ <br /> ------------------ <br /> ---------------• j <br /> ---------------•---------- -------------•------•--------------------••----------------------------•-•-------.-------------------•-•----•-------------------------•-------••-------•-------------------------------- i <br /> .1 - <br /> -------------------------------------------------------------------••--------------------•-----------------------------------------•-•----•---------------•-------------------------------------------------------- <br /> IF hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordin� nces, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> I <br /> (Signed)------- -' -------- ----------- -------------------- ---------------------------------------(Owner and/or Contractor] <br /> -----------------------------------------------------(ride) ------ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPL4CATION ACCEPTED BY--- - ---------------------------------------------------•------------------------------- DATE_------ <br /> ..----------- <br /> ­­ <br /> -- ----------------------------- <br /> REVIEWED BY----------------------------- ----------------------- DATE7� <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------•----------------------------- DATE-------__ _��------- ----- ----- ---------------- <br /> Alterationsand /or recommendations----------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> =----------------- ----------------------------------------------------- ------------- -------------------------------------------------- --------------------------------._.... --------------- <br /> ----------------- <br /> ---------------------------------••---------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------ ------------------------------------------------------------------------------:----------------------------------------------- --•----------------------------------------------------------------- <br /> ---------- -------------------- ------ ----------------------•-- --------•------------------------------..._.----------------------------------------------------------------------------------•---------------- -•--- <br />_ 5 �� r <br /> S <br /> FIN AL INSPECTION BY: C/ Date-------- <br /> ---- ------- -------�-'-��-------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> t <br /> Stockton, California Lodi, California Manteca, California Tracy. California <br /> ES-1h9-2M Revised W-2100 <br />