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APPLICATION- FOR SANITATION PERMIT Permit No. <br /> ,,- (Complete in Duplicate)V6. <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct an4s; th�work herein described. <br /> This application is made in compliance with County.Or mance No. 549. � �1 <br /> JOB ADDRESS AND LOCATION _ ._ -•-------------- � f <br /> Phn _ K, <br /> Owner's Name--- ---- ---- -=-- ----=` ----- - ----------------------- ---- - t - o e_ - <br /> - ---------------------------------------------------------------- <br /> Address.----- ._x x... _ -------- <br /> Contractor's Name--- --------------- 7- <br /> 1i <br /> Phone <br /> Installation will serve: Residences Apartment House ❑ Commercial ❑ Trailer Court JM .#/�sr❑ Other <br /> Number of bedrooms 3_-. Number of baths __�___- Lot size-"'�--I---� x ���----- --------- <br /> Number of living units: . tt <br /> Water Supply: Public(system-0 -Community-system ❑" Private ❑ Depth to Water Table ------- ff.s <br /> Character of soil to a depth of 3 feet: Sand ❑ GraSel ❑ Sandy LoVNo <br /> Clay Loam ❑ Clay ❑ Adobe/Hardpan ❑ <br /> Previous Application Made: Yes ❑ No R/ New Construction: Yes ❑ <br /> pP � � } <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> ( p or cesspool per -ted if public sealer}is available within 200 feet.)( q <br /> Na septic fank �15Lfy�/ 1 Material ----- -------- -- ---- <br /> --- <br /> Septic ank: D�wstance from nearesr well _ ____-___Dista cte fro (bun tion_____ - rI <br /> p - ------- <br /> _-Liquid depthp __.._1___ -- ---'Capacity_._ -No. of compartments-.----------- Si a%-X qi <br /> F <br /> [Z:! <br /> ---------- <br /> Length <br /> p stance from foundation__ __.___ _ (stance to nearest.lot in p� <br /> Disposal Field: Distance from nearest I ___--4-.______ f( <br /> Number of ,lines______}___ _-__.�!_.____ Length of each line_____--_ __ `"_ _ idth of trench___- _ '_______________ <br /> ® t t <br /> 1 Type of filter maters . - t epth of filter material-___.____I- - : ----Total length ---- _ [-------------------- (_� <br /> ,. _ . <br /> Seepage Pit: Distance to nearest well __`_-".._ _`Distance from`foundation__"_ `__-:-----.Distance to nearest lot line_________________ <br /> i ❑ <br /> NL <br /> imber�of pits----------------------Lining material-----------------------Size: Diameter---------- -------.,-,-.Depth--------------------------------- <br /> Cesspool: <br /> '-.Depth--------------------------------- <br /> Cesspool: i Distance from nearest well--------------__-Distance from foundation._----------------_Lining mat erial______________________._____--_____ <br /> ❑ }S�iz� Diameter---- -----------=--�` ,..��.�.,Depth----a-"-`------=-_`�_.�_..,...,..._�----Liquid.Capacity- ------------------ -- <br /> gals. <br /> Privy: Distance from nearest well----------------------------------- -------------Distance from nearesT building------------------------------------------ <br /> El Distance to nearest lot line.----- ------------------ -------------------------------------------------------------------- ) <br /> t. Remadelinc, and/or repairing r(describe7 = <br /> 1 r� ------------­-------- ---------------------------------------- <br /> ------------- <br /> -------------------------------------------------------------------- <br /> = <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 /> IL (Signed)-------- ------------------------------- -------------------------------------------- ---------(Owner and/or Contractor) <br /> ------- --- ---- <br /> gY�-----••-•--'---------••-------------- • - --- - -- ---------------------------------•---(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 /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- --------------- --------------------- DATE ---------------------------------------------------- <br /> -- <br /> REVIEWEDBY DATE--- '---------•-------------------------------------- <br /> ------ DATE-------- ----------------------- - <br /> BUILDING PERMIT ISSUED_______________ - ------------•-------- <br /> Alterations and/or recommendations:.__------ ---------- ----------------- _�---------------- ----------------------------•--------------------.----------------------------------- <br /> - -° 'v� e .�*, -` - -----•----------------•------------------•-•----------------------•------------------- <br /> ----- <br /> ------------------- ----------------------------------------------------- <br /> ----------------------------- <br /> FINAL INSPECTION BY:,-- ---------------I-------------------------- ----------- Date----- <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 /> a <br /> r <br /> E$-9-2M 10-52 Revised W-2100 <br />