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S APPLICATION FOR SANITATION PERMIT Permit <br /> (Complete in Duplicate) <br /> Date Issued�y��3�— <br /> pplica 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 with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION-------- Q a-----�----- <br /> Owner's Name--------------------R A411,M e"Vg---------- -'`d� Phone <br /> --------------------- <br /> Address----------_-----_------------ 77 "---------�-.-Y 7'4-A----S2-----------------------­-- <br /> Contractor's Name--------------0. . ......... :r3 i Xy N 'y Phone " <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ -Motel ❑ Other [❑ <br /> Number of living units: __�--- Number of bedrooms _1_._ Number of baths _j___ Lot size _ G____A-_--d_ 2_0_________-_______________ <br /> Water Supply: Public system JM Community system ❑ Private ❑ Depth to Water Table .` Q ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ® Hardpan ❑ <br /> Previous Application Made: Yes ❑ No a] 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 Tank: Distance from nearest well---&.!W! Distance from foundation_____l4___"._.Material____C_ __ �?' 4/� - <br /> No. of compartments---------a.------------Size-- ---r Liquid depth----- _- .......... <br /> Capacity_;flI7.2__�ra�- <br /> Disposal Field: Distance from nearest well _y_NdNE Distance fromfoundation____-- ___(.__.Distance to nearest lot line__;'_(I__f____ <br /> Number oz lines------------/------------------- Length of each line----------/L--- ---__._.Width of french.____-P__v----------------------- <br /> Type of filter material-_� --"- �t_ h!-Depth of filter material f-rr-----------Total length----------1. 1-__________________----- t <br /> �/_�F} r <br /> Seepage Pit: Distance to nearest well____ l_r _ 4__Distance from foundation___'X_ _______.Distance to nearest lot line__.p_ __. <br /> 0l.umber of p ------Lining material_�C---�('oDt't/:Size: Diameter------- -7----------Dept _____ <br /> sts-__._____t!__._ <br /> Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material__.---___.._____._.____..___._______ <br /> ❑ Size: Diameter.-------------------------- ----------Depth----------•-----------------------------------------Liquid Capacity- -------------------------gals. <br /> Privy: DFistance from nearest well-------------------------________________________Distance from nearest building_____________________-______________...._ <br /> ❑ Distance to nearest lot line---------------------------- <br /> Remodeling and/or repairing (describe)-------------------------------------------------------------------------------------------------- ------------------------------------------..-•--- <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 ws, and rules and regulations of the San Joaquin Local Health District. <br /> r <br /> (Signed)-------------- ` ------(Owner an or Contractor) <br /> By:.--- - x ` ------------------------------------------------------------(Title)--- "F {' ;' <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 /> REVIEWED BY---------------- -------- DATE <br /> --------------------------------------------- <br /> BUILDINGPERMIT ISSUED--------------- --------------------------------------------------------------------------------- DATE_._.---- Qr------------------------ <br /> Alterations and/or recommendations--- ------------------------------------------------------------- --- -------------------------••----•--- • ------------------------------------- <br /> -•------------------------------- ----•--- -----------------------------•---------------------------------- ----------------------------------------------------------•-•-------------------------------•-•--------•--------_ <br /> ---------- ------------------------------------------------------------------------------------------------------------------•--------------------------------------------------------•-------------•-•----------------------- <br /> ------------------------------------------------------------------ --------------------------------------------------------------------------•--------------------------------------- --------------------------- <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-9-2M 10-52 Revised W-2100 <br />