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APPLICATION FOR SANITATION PERMIT Permit No. U... <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 Ordinan I <br /> JOB ADDRESS AND LOCATION + !- <br /> ,,��jj <br /> _ <br /> Owner's Name----------------------------------------------- -' 4- --•-- M-!-f 0ALOW - -------------------------------- Phone--.. <br /> f� ------ --- ---- <br /> Address-•-------------------------------------------------AN?- ----F"2=...A. .r �d��, ..- <br /> Contractor's Name--------------------•-----------------------------------.------_��___e--- —- --- ----------------•-- ---------------- Phone- Y=7 _"?---------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> ____ Number of bedrooms . ____ Number of baths __ ____ Lot size .-__ i <br /> Number of living units: _1 �/ � �„�____�_,_�_�______________________ <br /> Water Supply: Public system )j� Community system ❑ Private ❑ Depth to Water Table <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe j ' Hardpan ❑ <br /> Previous Application Made: Yes ❑ NoX. <br /> New Construction: YesVT No ❑ ' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public s �y i available within 200 feat <br /> Septic Tank: Distance from nearest w Distance from foundation___`______-_.Aattriaf-------___________________ <br /> No. of compartments _________Size ' � '' <br /> p q �---'-C--3-------��- ._Liquid depth--- � ----------.Capacity-----�W <br /> Disposal Field: Distance from nearest wellJ�-7_._Distance from foundation---/p 7-____-_-Distance to nearest lot line-,S--. ____ <br /> Number o-i iines----l_____`�_ ,/ Length of each line_____ 4__''------------.Width of trench !!___________________ ' <br /> Type of filter material___ `__ _ _ - .___Depth of filter material______ftf_.______Total length_._--_��0____________________________ <br /> See a e Pit: Distance to nearest well 0---------------- fro f undation___`��_____. <br /> (, $ ____ _ Distance to nearest lot line..... <br /> Number of its.__ Linin material_ j-____-Size: Dia mete r____e .�_��_____- Depth p /------------- g p 1;�ar <br /> Cesspool: • Distance from nearest well _-_____-_ ------Distance from foundation-----_--------------Lining material_-___-__-_-.___-_-_-____-___________ <br /> ❑ Size: Diameter--------------------------- ----- ----Depth------------------------------------------------- - Liquid Capacity- -------gals. <br /> ' <br /> Privy: Distance from nearest well------------------------.-----------------------Distance from nearest building____________________ ____---------------- <br /> ❑ Distance to nearest lot line -- --------------- ------ -------- ------------------------------------------------------------------- ---------------------- <br /> Remo elfin and or airing <br /> describe :__ __________ ,, <br /> g / p 9 I ) � 'f ` �`' ---••-- --- -••---------I-------------- <br /> - -- --- --------- --------- ------------------------- <br /> - - -- - - ------------------------------••------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that 1 have prepared this app rca 'on and fhat the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of th Sann Local Health District. <br /> (Signed) ------ ----------- ------------------------ Contractor) <br /> I <br /> BY: -----------------------------4­1 � ------------(Title)---- - 1 - --�..J.------------------- <br /> r�'' <br /> (Plot plan, showing size of lot, location of system in rto wells, buildings, etc., can be pl ced on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY--------------------------- •- /_ /�_ DATE �} - -- `;y <br /> ----------------------------------------------- <br /> REVIEWEDBY------------------------------------------ ------ -------------------------------------------•-------------------- DATE- ---- -- ------ •----------------------.... <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------- --------- DATE------------------------ <br /> Alterations and/or recommendations--------------------------- .--------------------------------------- <br /> 94 , - <br /> --------- <br /> --•------------ ------------------------ ---------------------------------------------------- <br /> ----------I----------------------- <br /> -------------------------••---------------------------------------------- ----------------------------•--------------- ------------------------------l2-✓nQ---- ---------------------------------------------------------------- <br /> ------------------­-------------------------------------------------------------------------- <br /> --------------------------------------------------•----------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- <br /> -- ------------------------------------------------------------------•----------------------- ----- ----- <br /> ,/ <br /> FINAL INSPECTION BY______________°�`�'.- -� �� <br /> - --------------------------------------- Date------------- <br /> SAN <br /> ----------- --- �-- <br /> • r <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 10-52 Revised W-2100 <br />