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APPLICATION FOR SANITATION PERMIT Permit No- --..r?-.l <br /> (Complete in Duplicate) - j <br /> Date issued <br /> Applica-lion 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. 5 <br /> -7---- -- C - ,.�r <br /> JOB ADDRESS AN LOCATION---------------- -- --•- --- , ------- <br /> Owner's Name------0-11-1-A41-11 ----- - - -,--------- - ---------- ------------------------ -------------- Phone------------------------------------ <br /> Address------- <br /> ----------•-------- - <br /> Address------- <br /> ------------•----------------•---------------------------•----- <br /> Contractor's Name--.-- - - ----- ---- --------- r +� <br /> Phone •- <br /> ---- ------------------- -- - - - <br /> Installation will serve: Residence &0011partmenf House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _-I_-_ Number of bedrooms _q2--- Number of baths /---tLot size ----�_,--_49--116----K _ ---------- <br /> Wafer <br /> ------__Water Supply: Public system 9—C."rmunity system ❑ Private ❑ Depth to Water Table _ - ff. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ldpan ❑ <br /> Previous Application Made: Yes ❑ No ', lew Construction: Yes (r�.8._ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> k (No septic tank or cesspool permitted if public sewer is available=within 200 feet.) ` <br /> Septic Tank: Distance from nearest wellDistance from foundation----/0-_-----.Material--------- <br /> -------- <br /> No. of compartments__.-.- r <br /> Size y4----Liquid depth--- I---- <br /> _ ,{�-�! Capacity- -_fE-__--. <br /> Disposal Fie#d: Distance from nearest well_ _Distance from foundation-----/_0--(__Distance to nearest lot line---- <br /> r <br /> 9 7 Width of trench.---2_Y_-"--_-_------_--..- <br /> Number of lines_.--_-.-_-�--._.__f-- ___ __ -Len Length of each Line___.---- � � <br /> Type of filter material---�__ _____�---Depth of filter material---'r- -----------Total length-_--�-_----------------------------- <br /> Seepage Pit: I Distance to nearest-well ...--Distance f m foundation_-- -.Distance;to,-nearest Iot,Gne._ - <br />'r "� mber of pits`--� ~--....-_L ning aferial-- �wr�/��Size:'Diameter-. <br /> } -4--- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation_...................Lining material--..----..--_-.-______-----___----_-. <br /> ❑ r Size: Diameter- ....-'----------------------------Depth------------------------------------- -------------Liquid Capacity----------------------------gals. <br /> Privy: Distance,from nearest well-------------------------------------------------Distance from nearest building----------------------------- <br /> ------------ <br /> El Distance to nearest Ibt line ------------------------------------------------ <br /> Remodelingand/or repairing (describe):--------- ------ ------------------------------------------•-----------------...---------•----------------------------••------•------•-------- <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 I <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Sign ed)y:. d _ (Ti+le) -�- <br /> -� <br /> Contractorj <br /> - ------------------------- ---------------------------------- <br /> ------------------ <br /> (Plot <br /> plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> 6 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED,BY------------- ------- ------ --- ---- ---- ----------------------- -------------------- DATE------ <br /> ------------------------ - - - <br /> REVIEWEDBY----- ---------------------------- ---- ------- - --`--- �`� -------------------------------------------------- DATE------- - ---- <br /> BUILDING PERMIT ISSUED ---------------•---------------------------- DATE..-.----------- -------- -- --- <br /> Alterations and/or recommendations:-----...._-_ <br /> -----•-•-------------------------------- --------------------- --- <br /> -- ------------------------------ \. <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 145446 ATWcna 12-54 <br />