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APPLICATION FOR SANITATION PERMIT Permit No_cate ________________________ <br /> (Complete in 'Duplicate)p� ) Date Issued --!A-)- <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 Cc Or�nance No. 549. <br /> / . <br /> JOBADDRESS A O IO U� -----•- ------------------------------ ------ -- ------------------------ <br /> Owner's Name ,C ---- Phone{. ---- <br /> - �r - <br /> Address ` --•• ------------------------------------------------------- <br /> •. •-- <br /> Contractor's .Name.-- -------- •-- V/ ---------- Phone -------------- <br /> - <br /> Installation will serve: Residence g Apartment House ❑] m rcial [-] Trailer Court ❑ryMotel ❑ Othef ElNumber of living units: ___I___ umber of bedrooms �J---- umber of baths .__ __. Lot size ------ -------- i <br /> Water Supply: Public system Community system ❑ Private'[] Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel [j Sandy Loam Clay Loam El Clay El Adobe Er/Hardpan E]Previous Application Made: Yes ❑ No New Construction: Yes gNNo ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted 'f public se r is available within 200 fe9t.) <br /> Septic 46nk: Distance from nearest welC�-_G Stan a fromfglu�datiIr� ---------- 'Mat i I4 f <br /> No. of compartments_.___._ Li uid e h - ..__...__..___Ca acit .__ ---- <br /> Distance to nearest to line_�9?_.__..__ <br /> DisV <br /> Field: Distance from nearest wek _4Distance from foundation_/_�______.___ .. � L <br /> Number of lines--------- -----4�--- ----- ---Length of each line------------- rf------Width of trench.----_rr.-- r.________------ <br /> Type of filter mater '* Depth of filter material______1_ -------Total length______ !__t s�__•---------------- <br /> a <br /> Seepage Pit: Distance to nearest well____________ ______Distance from foundation--------------------Distance to nearest lot line-------------.... <br /> El Number of, pits-------------- L.ining material--------------- ------Size: Diameter----------------- --Depth--.------------------------------ 1 <br /> Cesspool: Distance from nearest well--------_--------Distance from foundation__________ --.___.Lining material------------------------------------- 00 <br /> ❑ Size: Diameter.----- ----------------------- -------- Depth----------------------•----- --------- ------Liquid Capacity----------------------------gals. <br /> k Privy: Distance from nearest well------------------------------------------------Distance from nearest building-----------------------------------------. L4 <br /> ❑ Distance to nearest lot line---- --------------------------------------------•-- -------------------------------------------- <br /> ---------------------------------------- <br /> Remodelin and/or repaifing idescribe):_______-------------------------------------------------------------- ----------------•----- -----...--------------•--------------------•--- ----•- <br /> -- -- - - - •--------------------- ---------- <br /> ----------------------------------•----•----------•---------••----------•-----------•----------------------------------------------.-....-------------------------------- p <br /> -- ------------------------•---------------------....----•--•---------•----•-----•-----------....-----------------•------------•--=----------•-•--------------•---------------------------------- - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t,L <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> fd(Signed)------•---- ---fes'-F-------- 4�Aj -- ---------------------- ----------------------•----------------- ---------------------• (Owner and/or Contractor) <br /> ---------------------------- <br /> By:----------------------------------------------------------------------------------=--------------------------------------------------(Title)_....-------------------- <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 /> APPLICATIONACCEPTED BY- -- -- --------------------------__..----------- -=-------------------------------------- DATE f ---------=---- -------------------------------�--- <br /> REVIEWED BY DATE__-------------------------------------••-------- <br /> BUILDING PERMIT 155UED ---------------- - DATE.: <br /> Alterations and/or recommendations:--- --- - ----- -----------------------------------------------------------------•-•--•---••--------•---•------------------------------- <br /> ---------------------------------------------- <br /> --------------------------------------------------------- <br />' --- '------- ------------ --------•-----------------•-----------------------•-------- ---•------------- <br /> FINAL INSPECTION BY ......:........_. ---------- <br /> -- ------- ------ Date---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 Soufh American Street 300 West Oak Street in Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5--9-2M 145446 nrw000 lz­ <br />