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.� PPL1CATi®N FOR SANITATION PERMIT Permit No. .41 `. ._ <br /> / (Complete in Duplicefe) <br /> Date Issued _____ __ <br /> Application is hereby made to the an oaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in complian a ifh County Ordinance No. 549. r <br /> JOB ADDRESS yAND LOCATION------------ ----- ----­------------ -- - = <br /> y <br /> Y ---------�� -------------------------------------- <br /> - ---- <br /> --- . - ---------- -- Phone <br /> --------- --------- <br /> ----- ---- --- - ----- ------Owner's Name <br /> Address s ----- <br /> -•------------------------- <br /> ontractor s Name- <br /> --------- --- ------------------------------- ---------------------•--•--=--------------------••------------------•---- Phone------------------- -------------- <br /> Installation will serve: l Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [j Other <br /> Number of living units: _S--- Number of bedrooms Number of baths ---- Lot size ---------- _x_-.0 � <br /> 1 R <br /> Water Supply: Public system 5�K_Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ <br /> � Sr <br /> Previous Application Made: Yes 9--No4❑ New Construction: Yes No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permifted if public sewer is available within 200 feet.) <br /> 1 ,'„ - <br /> 'Septic Tank: Distance from of compartments--,nearewell_ __ -__ : ._-_D setance from foundation____________ ------_Material__.____._____-____-----_________..___._.___.No. ... <br /> Liquid depth ___ __ _ _ Ca acit _ <br /> + ------- q p. Capacity :-.. <br /> Disposal Fiel • Distance from nearest-weEl____..0-W-L-Distance from foundation_-O.__ .___'Distance to nearest lot line___P.- <br /> Number of line's-----------/_____________________Length of each line_____----_-- ' Width of trench.-_-__.. � � <br /> �,� 1, T-------------- <br /> Type or,filter matenal�__�______________Depth of filter material ------Total length_________ ���__________________-_._ <br /> Seepage Pit: Distance to nearest well-----------------------Distance from foundation--------------------Distance to nearest lot line-------------- -- <br /> �" ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Deptn__------------------------------- <br /> cesspool; <br /> --Cesspool: Distance from nearest well-----------------Distance from foundation---.--------------- Lining material---------.__---._________-__________- <br /> ❑ Size: Diameter------------------- -------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance fromnearest well________________________________________________Distance from nearest building.____.._____.___.________-__-----._____.. <br /> ❑ Distance to nearest lot line------------------------------------ -------- --------------------------------------•---------- ---- <br /> Remodeling and r re 'ring (describe):------------------ �3� ------- ---.---�------- d� <br /> �^ rc <br /> ---------------------- -- ------ :.. k £•----`!------------ ------ <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 /> i <br /> • (5i ned <br /> 9 )-------------------------I--•--;;----- - -� � --- --Y---- - -- -- --- ---•----- •- ----------------------------------------------------(Owner and/or Contractor( <br /> BY: ---------------------------- <br /> ----------- -- ----------- ------------------ ------------------- ------(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____!'___________<_____ -�-- ----- J <br /> - -- --------------------------------- DATE-------1-•---•---------------"------------- -- - <br /> REVIEWEDBY ------------------------------- ------------------------------------------------------------------- ---••------- DATE---- ---------------- ' <br /> BUILDINGPERMIT ISSUED---------------'---------- *-------- ----------------------- DATE------ ------------------------------------------------------ <br /> Alterations and/or recommendations--------------- --- - - ----------- ----.. ---------------•----•------------------------ <br /> -------------------------------------------------------------------------77 <br /> •-------•----------------- ---------------- <br /> ---------- <br /> ------ ------ <br /> -•------------• -------------•-----------------------.. . <br /> - - - -------------------------- <br /> -----------------------------------••-•------- ----- •---------------- <br /> ------------------------------------ <br /> ----------------- <br /> ----------------------- <br /> -------------------------------------------------------------------•-----------------------•----------------------------------------------- ----------------------------------- <br /> FINAL <br /> --------------------------------FINAL INSPECTION BY:----� ------------------------------------- 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 /> ES-9-2M1 10-52 Revised W-2300 <br />