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1 <br /> APPLICATION FOR SANITATION PERMIT Permit No. . .__ .L <br /> (Complete in Duplicate) <br /> � f -, � ,• �. 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 Ordinance No. 549. <br /> .-- S � ---/ <br /> JOB ADDRESS AND LOCATION..-----r-fir--- --------f� � � <br /> -�_S_ -------�-�--�--.. --------------------------�---------- -�--- <br /> --7--------- <br /> J } E <br /> Owner's Name---- - -------------- --------------iN_-1------ � p ---------------------------- Phone----- <br /> --AddAddress----- <br /> ress----------•---------------------------------=-----• ----- <br /> Contractor's Name------Q ..-''� -------------- Phone----------------------------------- <br /> ---------------------------------------------------------------------------------------- <br /> Installation <br /> ----------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel [❑ Other ❑ <br /> Number of living units: Nu ber of bedrooms _ Number of baths __I-.. Lot size -___t_!r0__X1-----Z94v� ------------------ <br /> Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to-a .depth of-3 f8ef SanGravel E] Sandy Loam ❑ ay Loam E] Clay E] Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes E] No New Construction: Yes No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Ta ,Distance from nearest well---_C�____Distance from four) ation-_-J--:�-_-.-__.Material___, _ ------------------------ <br /> No. of compartmen.ts__._ ""D Size____ __X_�ij_�s ,--_Liquid depth._._ / -_Capacity /.4.40'0.__i ` <br /> Disposal F" Distance from newest well.__<,f_ _Dlsfance from foundation_- !� ---- st nce to nearest lot line------ . <br /> Number of lines--..---._-_-----=---- -----Length of each line ^-9.___.Width of trench-__-_;�4 t�_.__. <br /> r r <br /> 'SType.o7 filter mafe�ial_ __ _ _ _ De th of filter material ��!fofal length-------------J-��_------__-..---- <br /> .* ,�... . <br /> Seepage Pit: Disfance to nearest well-----------------------Distance from oun cion___.---------__-___.Distance to nearest lot line--__---_--___-_--� <br /> ❑ Number of pits.._;_----------------Lining material-----------------------Size: Diameter-------------------------Depth-.------------------------------- <br /> Cesspool: ,_.Distance,froni nearest well-----------------Distance from foundation--------------------Lining material ____._____.._-__-______--_.--.---. <br /> Size: Diameter___-.__'____.___._ __ De'th Liquid-Capacity..--,--- <br /> P --------------------- <br /> Privy: <br /> - — <br /> Distance from nearest well____-_-._---------------------------------------Distance from nearest building_____-_.--------------_-_--_--_...___. <br /> ❑ Distance to nearest lot line-----------------------`--------------------------------------------------------------------------------- ---------------------- X <br /> Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> i.:. - ------------------ <br /> - ----------------------------------------- ---- -------------------------------------------------------------------------------------- ----------------------------r----------------------------------------------------- <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, 5f awn rules and regulations of the San Joaquin Local Health District. <br /> [Signe ---- - -- b. •- ----------------------------------- --------- ------(Owner and/or Contractor) <br /> ---- --- - <br /> BY: •-••-------- ...........................`......j-...-•-------- ------------------------------------------------------------=----(Title)---------- ---------------------------------------------------- <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----------- c! 7 <br /> REVIEWED BY - -------------------------------------- DATE---------- --- --------------------------- <br /> BUILDING PERMIT ISSUED...... I----------------------------------------------------------- DATE------------- -------------_ - <br /> Alterafions"and/or recommendations:-------------------------------------------------------------------------------------------------------------------------------...------ --- <br /> - ---------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------•---------- ------------------ -------------•------------ ---------------------------------- •-----•- --------------•--------- ----------------------- ------------------ - ------------------------------ <br /> FINAL INSPECTION BY------------- � Date---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,&-South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California E Manteca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 <br />