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APPLICATION FOR SANITATION PERMIT Permit No. .......... ........... <br /> 1(Complete in Duplicate) f 1� <br /> Date Issued -- <br /> Applica;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 /> ---- --------------•-----. ...._.- <br /> JOB ADDRESS AND OCATION___._..._�__ __ __ ___ _____-:_ <br /> Owner's Name--- --•---Ui - -- ---------------- Phone <br /> Af__ <br /> Address---------- - �-•_----`••--•--•--•--------------•--------------------------------------------------------...-------------._._...... <br /> Contractor's Name----- ---�--'.`-"`------------------------------------------------------------- Phone. �9�� ------ <br /> installation will serve: Residence 3---Apartment House ❑ Commercial ❑ Trailer Court []. Motel ❑ Other ❑ <br /> i <br /> Number of living units: -_�___ Number of bedrooms __�.-. Number of baths ./-. Lot size ____7S X�4Q <br /> ------------------------ -------------- <br /> Water Supply: Public "system ❑ Community system ❑ Private 2--�Depth to Water Table 4/ t. <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 9?---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 /> Opti Tank: Distance from nearest well__;-__.__--:___Distance from foundation--------------------Material ________-__._____-___.________.___--.---_.__._.. <br /> No: of compartments------ ----- -----------_Size------------------------•-- ---Liquid depth--------------------------Capacity----------------------- <br /> 1L <br /> p tante from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line_________________ <br /> Disposal, geld: Number of lines----------- ..:.--Length of each line-----------------i------------Width of french----------------------------------- <br /> Type of filter material--------------------------Depth of filter material------------------------Total length <br /> ^' <br /> length------------------------------------------ <br /> Seepage <br /> ___-__-___--._.___l_i_n__e____-__--•_.__-_-.-__._..- <br /> ._ <br /> Seep ge Pit: Distance to nearest well_.` 0__._,,______Distancefrom foundation- .. ..........Distance to nearest lot <br /> Number01/ <br /> of pits _____________Lining material--&-!C&------:Size: Diameter-33-----_.-_-_..Deptn___as--__________________ <br /> Cesspool, material <br /> rL <br /> eVi <br /> Distance from nearest well_________________Distance from foundation----------_--._____.Lining material___-__-__.-;-_----._--___________--- <br /> ❑ Size: Diameter----------------------------- -------Depth-----=------- ----------------- --------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well ____________-------------------------____----------Distance from nearest building--------------------------------_.___-___. <br /> ❑ Distance to nearest lot line--- —------------------ ------=------------------------------••--•--------- ----- ---------------- ------------_---------- <br /> Remodeling and/or repairing (describe}: ---------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------ _... <br /> --------------------------- <br /> -------------_--------------------------------------------------------------------------------------------------------------------------------------------------- <br /> y <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, laws and rules and regulations of the San Joaquin.Local Health District. <br /> --(Signed)---------- ----- --------- ----- Owner and/or Contractor <br /> ). <br /> By:--------------_---_--f�•r..1 . L�f/r�=-�� r --------`- ----- (Title) <br /> (Plot plan, showing size of lot, location of system n relation to wells, buildings, etc., can be placed on reverse side). <br /> u FOR DEPARTMENT USE ONLY { <br /> APPLICATIONACCEPTED BY---------------------------- __7-- ----- ---------------------------------- DATE----------��s------------------------------------------- <br /> RIE E PERMIT ISSD BY ---------------•--------------------------- - --------------- -------------------•--f----------•-----• • DATE----------------N-----------------•-•------_----------- <br /> DED------------------------------- -------------------------------------------------------- DATE..-------- •- -------- <br /> ----------------------------- <br /> Alterations and/or recommendations *• ------------•-----------------=--------•-------•--------------------------- <br /> -_ 1....' �.......................... <br /> , ,✓� = --•-- -------------------------------------- --•-••-----•------ �� <br /> ----- ----- <br /> -- ------ ---- <br /> ' <br /> ------------- ------------------------ ----------- ------------ - ---------------------------------------- ------- <br /> i <br /> .;� T , <br /> �j <br /> FINAL INSPECTIOI\I BY:.._' ----------------------------------------- Date---- "" ? Y --------------------- ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Sfreef 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> us-- —2M 145446 ATWOOo 12-54 <br />