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110APPLICATION FOR SANITATION : MIT Permit No. � __!_... <br /> (Complete in Duplicate) . <br /> Date Issued � 1-3 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to co struct and install t ork herein described. <br /> This application is made in compliance with County Ordinance 54 . <br /> l - ------------------- <br /> JOB ADDRESS AND LO ION-------�---�- ------------ - - --- ---- ---'�-'--� ....... <br /> --- ------ <br /> Owner's Name-----••-------- - -------------- ---- ------- ------------------------------------------ Phone-�' - (�' I <br /> g Address-----------------------_-- -------------- ----------------------- - ----- ------------ --- - --------- -------- ---------- - <br /> - ---- -- ----- <br /> ------- ------------------- / -- <br /> Contractor's Name----------------------•--....----------- '- - ---- - -------- Phone---- <br /> Installation will serve: Residence a Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: I----- Number of bedrooms _Number of baths'-/__ Lot size ©-------------------------- <br /> Water Supply:' Public system F1Community system -E] Private " Depth to Water Table 44 0 ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe A Hardpan.❑„ <br /> Previous Application Made: Yes ❑ No K 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-----------------Distance from foundation---------------.___Material_-_-------------___-______,_-__-________---. <br /> ❑ No. of compartments------------------- ----Size--------------------------------Liquid depth--------------------------Capacity---------------------- <br /> Disposal <br /> --- ----Disposal Field: Distance from nearest well 6,Q--......Distance from found ati9n_- ------- _--__-Distance to nearest of line <br /> Number of lines Length__-- --Length of each line Width of trenchj - --------------------- <br /> Type of filter material_ yy__-__�,_-+_Depth of filter material---------____-------Total length__--.LA-a--------------------------- <br /> Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line--------_-------_ <br /> ❑ Number of pits----------------------Lining material----------------------Size: Diameter---------------------_-.Depth--------------------------------- <br /> Cesspool: <br /> -----------_---- _----._Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------- <br /> ----------------------- � <br /> ❑ Size: Diameter------ -------------------------------Depth--------------------- ------------------- ---------Liquid Capacity-----------------------------gals. <br /> Privy- Distance from nearest well-------------------------------------------------Distance from nearest building -_ ------_-_--. <br /> ---------------------------------------- ----------------------.--- ------------- <br /> ❑ Distance to nearest lot line--------------------------_-_--____-__-----..-.-_.....- [� <br /> Remodeling and/or repairing {describe):-- -6Z� 61-------�--•------- ------------------------ <br /> --------------------------------------------------- -- r <br /> --------------------------------------------------------------------------------------- ------------------------------ - ------ -------- <br /> ------------------------------------------------ ---------------------------------------------------_....----------------------------------------------------------------t/-------------------------------------------- <br /> hereby cerela , <br /> hat I have prepared-4his application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State an ules and regulations of the San oaquin aI Health 'strict. <br /> (Signed)----------- ------ ----------- --- - -- - - - -- - - --------------- ---- ---- b R (OwneJ a d'/ar C niracvoe) <br /> ---(Title)------ - ---------s �------------- <br /> b <br /> (Plot plan, showing size of lot, location.of system in relafi n to wells, buildings, etc., can be plat on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------------------------------- DATE...._ --- <br /> REVIEWEDBY--------------------------------------------------------------- ------------------ ------ - -------- DATE--------- -------- <br /> BUILDINGPERMITiSSUED---------------'-------------------------------------------------------------------------------------- DATE---------------------------------------------------- <br /> Alterations and/or recommendations--------- ------------------ -- - ---------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------- ---------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------ ------- -------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------- - --------------- - -- ------------------------------------------------------------------------ <br /> FINAL INSPECTION BY:--------- } ------------------------- Dafe__/_D/­­­__r)­/­­­_,5_4---------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> 130 SoOh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5-9-2M 8-51 Revised W-2100 <br />