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c .. <br /> pw� A111ICATION FOR SANITATION PE MIT ' [5 <br /> (Complete in Duplicate) <br /> z Date Issued .......... <br /> �^Applica4,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 . <br /> with County Ordin o. 54 <br /> JOB ADDRESS AND LOC TION____.,_ _- -- - -- ' - __ - ----- <br /> ---(5 --------------------------------------------------------- <br /> Owner's Name -..� <br /> -^'�'-�-_..�� ----- ------ -- ------------------- ------------ Phone--�-�=Wit/.-•.------•--- <br /> Address,w �'�. .. -------- -- <br /> r <br /> Contractor's Name = = f -t----------------------------------------------------- ------ Phone___;;?_2-1- , <br /> Installation will serve: Residence Apartment House Commercial ) <br /> ❑ p ❑ ❑ Traiill�er Court ❑ Motel r❑ Other <br /> Number of living units: /-- Number of bedrooms 1,?-- Number of baths �.- Lot size _ _Q <br /> - ------------------ <br /> Water Supply: Public system ]� Community system E]- Private E] Depth to Water Tablet_ �ft. r <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ Nor' New Construction: YeNo ❑ ; <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 4 <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 <br /> Se #i Tank: Distance from nearest well---------.-------Distance from foundation-------------------.Material <br /> ---------------- <br /> _____________ <br /> h a r No. of compartments_--------- ._...._-Size________________________________Liquid depth----________.._. Capacity <br /> It <br /> ---------------------­ <br /> Dispos field: Distance from,nearest well------ ----------Distance from foundation--------------------Distance to nearest lot line-_-----__..____- <br /> Number of lines-----------------------------------.Length of each line--------- -------------------.Width of trench--------------- j <br /> Type of fiiter material-------------------------Depth of filter material-------------.---------Total length----._-.-_.._-_-:-_---_--_-- <br /> Seepa a Pit: Distance to nearest well. M�f .:____Distance f m f ndation----Q---,__.D-::stance to nearest lot line__., <br /> Number of pits_____.-------------Lining material Ar__.Size: Diameter. '."__,-----.Depth . <br /> Cesspool: Distance from nearest well_----.___------Distance from foundation-------------___-.Lining material_..__:__.___.______.___ <br /> ❑: Size: Diameter---------------------------- -------Depth..-------------------------------------------- ---Li uid Ca aci <br /> q p tY <br /> Privy: Distance from nearest well.-----------------------------------------------Distance from nearest building------------------------- <br />�. ❑ Distance to nearest lot line------- -------------- <br /> ----- <br /> ------------------------------------------- <br /> -0 4 O -0 <br /> Remodeling and/or repairing (descrie):_ __� �, <br /> �.-s - ° <br /> fy .---•------:---- <br /> -------------------•-------------------------=-----------------f----------------------------- •-----------------. --------•----•------------ -------------------------------------------•---------------------------------- <br /> ----------:------------ -----------------------------------------------------•--- -----------------..._..-------------------------•---------------------------------------------------------------------------------------- <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules rid regulations of the San Joaquin Local Health District. <br /> (Signed)--------.-- ----- I ------ •----------------------- Owner and/,pr Contractor)' <br /> BY ;f ---------------(Title) ' <br /> ----- ------- -------- <br /> (Plot plan, showing size of lot, ocefion of system in relation to wells, buildings, etc., can be plat on reverse side.. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------------- -- -- -----------_------------------------------------------- <br /> = DATE---------- <br /> J Gf / l <br /> REVIEWED BY--------------------- -- ---' - ------------ - - DATE--------- <br /> -------------------------- - ------------------------•--------------------------------------• DATE------------------------ <br /> ------------�•------------------•--------. , <br /> BUILDING PERMIT ISSUED.- <br /> Alterations -- <br /> and/or_recommendations:._------------------------------------------------------•---------------------•----------•--------•---..--------------•------------ , <br /> -------------------------------------------------------- - <br /> ---- <br /> y .------------------- <br /> -------------------_----------------------- -- <br /> .._._ ---------------------------- f <br /> ------------------------------------------------ <br /> _ <br />- FINAL INSPECTION BY:,, ----1�.---./ f Date <br /> --------•------ i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT -z <br /> a <br /> 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North •'C" Sfreef <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> -ES--9-2M Revised W-2100 <br />