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1Z <br /> APPLICATION FOR SANITATION PERMIT Permit No_ ----- ------ --- <br /> (Complete in Duplicate) <br /> Date Issued ----M-4_ Y <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 Ordi e No. 549. <br /> JOB ADDRESS AND�LOCATION___ --- - --- --- ---- --------- -- --- <br /> Owner's Nam <br /> - - ---------------------------------------- ------------------------- <br /> -- ------------- ie� ------ - <br /> Address-- --- <br /> --------------------- ------- ------------------------------------I-------------------------------------&---------------------------------- <br /> Contractor's Name______________----- <br /> -- ------- -------- -- ------------------- ------I------------------------------------- Phone- <br /> Installation will serve: Residenc?X Apartment H. se Ej Commercial El Trailer Court El Motel ❑ Other El <br /> Number'of living units: ----1"-- Number of bedrooms -41--- Number of baths _1___. Lot 'Size <br /> Wafer Supply: Public system Community system E] Private [-] Depth to Wafer Table.,-_:?O ft. <br /> Character of toil to a depth of 3 feet: Sand 0 Gravel [] Sandy -Loamb Clay Loam [:] Clay [] Aclobe_E!I�Hardpan E] <br /> Previous Applicaf ion Made: YesE]' N oi� n:New ConstructioYesA No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tan : Distance from nearest well_________________Distance from foundation__--_--_-_________Material <br /> No. of compartments------ -------------------Size----------------------- --------Liquid depth-------------- -----------Capacity---------------------- <br /> sa <br /> D;spol F1 Id Distance from nearest we4-------------- Distance from foundation--------------------Distance to nearest lot line_-_--___________ <br /> I - / --- <br /> Number of lines-----------------------------------Length of each line---------------- <br /> --------------Width of trench.---- <br /> Type of filter material--------------- ---------Depth of filter material-----------------------Total length___-______.__._______- <br /> ---------- <br /> ---------------- <br /> eepage <br /> ength--------------------------------------- <br /> eepage Pit: Distance to nearest well_______�__ ' e rpm foundafi <br /> ______Distance, f on---,./P-------- Disfpnce to nearest lot line----------- V, <br /> Number of pits---/----------------Lining D`iameter_____11r_I ,Z -------- <br /> Depfh___,�h� I--- 15 <br /> Cesspool: Distance from nearest well_________________Distaripe"from foundation________________- Lining material___.___.__.__-------___.._ q) <br /> El Size: Diameter------------------------------ ------Depth-----------------------------------------------------Liquid Capacity-,--------------------------gals. <br /> Privy: Distance from n6aresf well-------------------------------------------------I Distance from nearest building---____.__________---______ - <br /> F1 - .1 Distance to nearest lot line/--__/ <br /> Remodeling and/or repairing (describ _ 4V�� <br /> e):...... - -- ----------------------------------------------------------------------- -------------------------------------------------------- <br /> 10 <br /> ---------------------------I--------------------- ----------------------- ---------------------------------------------------- <br /> ----------------------- ------------------------------------------------------------------ <br /> --------------------- .7------------------------ ------------------------------------------------ ------------------------------------------------------------------------------------------------------------ --t <br /> --------------------------------------------------------------------I----------------------­-1-----------------------------------------I--­-------------------I--------------------"I------------------7--- ----- <br /> I hereby certify that I have prepared Phis application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Sfat ws,5apd ulle and regulations of the San Joaquin Local Health District. <br /> [Signed}--•--__-- ----- --- ................. <br /> .... ---- --------------------------------I--------------------------------------------------- (Own6rta:ndj�,6ir ontr <br /> "Ir C <br /> BY: w--- --------- ------------------------------------------------------------------------------- 4;70.5 <br /> 1� actor)- <br /> (Plot plan; showing size of lot, location of system i.n relation to wells, buildings, etc., can be Wd on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ---------------------------I-------------------------------------------------------------- DATE <br /> -------------------------------- ---- --------------------------------------- <br /> REVIEWED BY - <br /> ---- ---- ----- <br /> ---------------------------------------- ---------------------------------------- DATE-----3:9Z <br /> ---------------- <br /> BUILDING PERMIT ISSUED-------------- - ----------------------------------- ------"---------------------------------------- DATE------ <br /> A terations <br /> ATE------Alterations and/or recommendations <br /> ------------- ....................................­--------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------I--------------------------------------------------------------------------- -------------------------------------- ----------------- ------------------------------------11-------------------- -----------------­ <br /> -------------------------------------------------------------------------I------------------------------------------------------- -------------------------------- --------------------- -- -------------------------- <br /> ------------------------------------------ ----------------------------------------------------_---------------------------------------------------------------------L----------------------------------------------------- <br /> ------------------------------- --------------- - -L -------iS7 k <br /> FINAL INSPECTION BY:---------- Date------ --------- --------------- ---------- <br /> - ---------------------------- <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-7-2M 10-52 Revised W-2100 % <br />