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'APPLICATiON FOR SANITATION PERMIT Permit No. <br /> -�� (Complete in Duplicate) ,� �U <br /> .r T Date Issued -- <br /> Application is hereby made to the Joaquin Local Health District for a permit to construct and install the work h 2ndescribed.. <br /> This application is made in compliance with Count O finance No, 549 <br /> JOB ADDRESS AND LOCATION------------------------------------------ <br /> ---�-� ----- -4 ----- -- ---- <br /> --------- ----- ------------------------------------------------------------------ <br /> Owner's Name ----:-- -------------- ----------------------------------------- Phone----------- <br /> -------------------- <br /> Address-•----���_-------- <br /> ' - <br /> Contractor's Name--- 1 ---- -j0 -- ---------------------------------------- --------------- ------------------------------------------------- Phone------------------------- <br /> Installation will serve: Residence [v�Apartment House [-] Commercia E] Trailer Court ❑ Motel ❑ Other ❑ <br /> 1 <br /> Number of live g units- ___�_- um <br /> _ ber of bedrooms ___�:___ Number of baths ___LLot size __ ___________ :21 <br /> Number <br /> Water Supply: Publii system Community system ❑ Private ❑ 3epth to Water Table ________ ft. <br /> Character of soil to s depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loat Clay Loam ❑ Clay ❑ Adobe H rdpan E]Previous Application .Made: Yes E] No [/ New Construction: Yes VNO ❑, # <br /> TYPE OF INSTALL TION AND SPECIFICATIONS: <br /> [No septic tank or cesspool 1 prm+te f ublic s,wer ins availab[e�ithin 200 feet <br /> lstan fr foun ation_rr__ <br /> ----- <br /> Se tic ank: Distance from nearest Il___ ____. _ ( 1�--------- - ' <br /> p� cue _ ateri Ir------------------------------- <br /> No. of compartments------I.--- _------ Sizeo�., _ ��:---Liquid depth:--,------------ ------Capacity---- -- ^> ---- <br /> 1 Dis os field: Distance from nearest w ( Distance from foundationf _:�! . istance to nearest lot #in <br /> p i Jr -r--- r <br /> I Number of lines__________ --- - ___Length of each line__ .- :_._JX'Width of trench.__A <br /> f <br /> r d <br /> Type of filter maferi _ __c�Depth of filter mai-erial_______I__E,�- otal length___-______ ___-_'� __ _ <br /> See a Pit: Distance to nearest e _- ___ Distant fro foundatio _____-_ Dista c nearest Ia# line _ "? <br /> p � , �y r <br /> ber of pits-------- -_ --__---Lining material`itLJ_dS�dHSrCe Siie: Diameter____ Deptn_____-t?,e_�`J._._______-_-_ <br /> CA-4v <br /> Cesspool: Dis nce from near st well-----------------Distance from foundation--------------------Lining material--------------------------:________. <br /> ❑ Size: Diameter--------------------------------------De th----------=---------- -----------------------------Liquid Capacify gals. <br /> 1 Privy: lNistance from nearest well_____________________ ---------------------Distance from nearest building_____.___.____-___________-_-_-_._---------------------------------- <br /> El Distance D stance to nearest lot line----------------------------------------------- -- " <br /> r <br /> YbpI R modeling and/or rep irin {clescr6e):--------- -- = ---�--) ----------•'-••-- ?--------------------------------------•--- --------- <br /> Wilk <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 /> r <br /> Si ned -------------------------------------------------------------------------------------------- <br /> Owner and/or Contractor] <br /> [ 9 )----- " <br /> BY� -------------------------------------------------------------------------------(Title)----------------------------------------------- ---------------: <br /> (Plot plan, showing size of lot, I�cet�on of system in relation to wells, buildings, etc., can,be placed on reverse side). t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------- DATE --------------------------------------------- <br /> REVIEWEDBY--------------------------------- -- - - --------------------------------=----------------------------------- -------- DATE----�-----------------------------•----------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------- ---------------------------------- DATE---------V------------------------------------------------ <br /> Alterations and/or recommendations------------------------ <br /> ---- ---------•--------- ---------------------------------------------------------------------------------------------- <br /> " ----------- ���n--- -------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------- l-----l--------,--­--------------/----- <br /> ----l--------,-- - --�----•-----------I----------------------- _ <br /> '' " /Z -------------------- --------- -- - ----------- <br /> ---- - ------- ----------------------------------------- <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-9-2M 10-52 Revised W-2100 <br />