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tZ <br /> APPLICATION FOR SANITATION PERMIT Permit No. __----- <br /> (Complete in Duplicate) <br /> Date Issued <br /> Applica+ion is hereby made to the San Joaq Inu 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 LO ATION 6 1Y.d_ P ---------------------------------I--L) <br /> Owner's'Name------------- 1"6-. ----------------- -------•---•- ---------­------------ ----- - ------------------ ---------------- Phone------------------------------------- <br /> Address <br /> ----------------------------------- <br /> Address-----•......AE Y_ I <br /> r • - <br /> --•-------•----------- ------------------ -----•................... <br /> Contractor's Name. '.RJXR------- .- J `------------------- ----------------- Phone---------------- <br /> - - -----------------------------------� ------------------ <br /> Installation will serve: Residence ®'`'Apartment House ❑ Commercial ❑ Trailer Court ❑ . Motel-L],_ ❑ <br /> 11 r -- - <br /> Number of living units: _/__._ Number of bedrooms .___Number of baths -----/ Lot size ___:.7_._: ___..-_ __�Y-__[-_ ____.:_=___ <br /> Water Supply: Public system [E'F Community 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 S---Hardpan ❑ <br /> Previous Application Made: Yes ❑ No D__New Construction: Yes ❑ No - '• <br /> I: <br /> TYPE OF INSTALLATIOWAND SPECIFICATIONS: <br /> a (No septic tank or cesspool permitted if public sewer is available within 200 feet.) fib. <br /> Septic Tank: Distance from nearest•well -.Distance from foundation--------------------Material----------------------------------- -------- <br /> ❑ No. of compartments- ------Size---------------------------------Liquid depth---------- Capacity----------------------- <br /> Disposal Field: Distancei from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line_______----__.__. <br /> ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french--------------------.-------------- <br /> Type of filter material------------_------------Depth of fiber material------------------------ length-_-.:-._--_____________________'______-__.. <br /> r .r - 1 „ 01Seepage Pit: Distance to nearest well_//Q-�✓X-Distance'from foundation-----/-----0 <br /> to nearest lotline_. 4=____ <br /> Number of pits-------1..----------Lining material--of-/C- '--Size: Diameter--- ------------Depth-__-:- 3__---------------- <br /> Cesspool: Distance from nearest well---------------:-Distance from foundation--------_---±f_--,.Lining material------------- ------------------------ Q; <br /> ❑ Dr jr fDepth--------- -- - - -"---Liquid Capacity.........------------------gals. <br /> Privy: Dstae t omnearest well----------------- - - -Distance foambuilding <br /> N <br /> 'nearest buildin <br /> ❑ Distance to nearest lef'line------------------------------------------------------------------------------------------------------------- --------------------------------- <br /> Remodeling and/or repairing (describe):_.. _%./✓--------/r_ 'x......•-�!eF 7S ----- / ..----------•---------------•-------- <br /> ---------------•-•----------•------•------------------=•---:---------------------------------------------------------------------------------------------- -.._.. <br /> I 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'l8ws, and rules and regulations of the San Joaquin Local Health District.' <br /> 7 <br /> (Signed)------- = C ZF= er and/or Contractor) <br /> ...� �� <br /> BY� {Title) <br /> --- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> it FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------------------------- �1� `------------------------------------------- DATE - - -'-tI <br /> REVIEWED BY `= - �' ------------------ DATE------------------------------------- -------•------•---- <br /> BUILDINGPERMIT ISSUED---------------------------------------- ----------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations:-- ------------------ --- ------------------------------------------------------------------------------------------------------------------•-•=-------- <br /> r <br /> ---- •----- --------- ----- --- - I--- ---- -- ------- - - -------•----------------•---------------------------- -------- <br /> ---••---•--•------------------ ------------------------------ <br /> r' <br /> FINAL INSPECTION BY:----- ...- Date. ----------- ------- 8-------—.S ---------------- <br /> I; <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 145446 ATw000 ` <br /> 11 <br />