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e� <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> 1 <br /> (Complete in Duplicate) /� <br /> Date Issued ______ --G_ _ <br /> I Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> 49:TJThis application is made in compliance with County Ordinance No- 54q'.---­ <br /> JOB <br /> OB ADDRESS AV LOCATION.... --------------- �` `:.__ . <br /> Owner's Name_---- -- <br /> ----------_l _ h u" ------- •C-C.� `--------------------------- Phone------------------------•---• ---- <br /> y <br /> Address----------------- ...I------�-x--- ------------------------------ <br /> Contractor's Name ; -- ------------------------- Phone <br /> ---------- <br /> - ------------------ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer.Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ....I— NuAber of bedrooms __--Number of baths _�_____ Lot size .__�__�.____y __�_ _ ___ ____________________ <br /> Water Supply: Public system Community 'system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of Sand Gravel Sand Loam ❑ Clay Loam ❑ Clay Adob < Hard an <br /> P ❑,� ❑ Y Y , Y ❑ p ❑ <br /> Previous Application Made: Yes ❑ No New.Construction: YeNZ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: x <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: - Distance from nearest wall__ ._�L2___.__ Distance from foundation____f_�___-____".Materiel___ ",: <br /> -------•----- <br /> -- Liquid depth1----4-..............Capacity----- -Q- -�---- <br /> ---Size-___-•- �,-• ]_-_ <br /> Disposal Field: Distance from rnear nearest well--- . 0.. Distancef rom, undation tl1 .-_____-...Distance to nearest lot line---,.4----------- <br /> Number of lines-------------------- -- Le o ea h line--- -0 __-- _ r Width of trench.---- .r_ _ ------------- <br /> f <br /> T e of filter materialS_� .-- LCs,D eriaL__-_1_�!_-__—_Total len th___:__ ________ <br /> Seepage Pit: Distance to nearest well------------.---------Distance from foundation---------------------Distance to nearest lot line----------------- <br /> El Number of pits-_----------•---------Lining material-*-- ------ -Size: Diameter----------- ._._�--_ Dept h------ -------------------------- <br /> Y w <br /> Cesspool: Distance from nearest well-----------_-----Distance from foundation---------------'.Lining material.-"----------------------------------- <br /> ❑ Size: Diameter--------------------------- ----------Depth----------------------------------------I-------------Liquid Capacity----------------------------gals, r� <br /> Privy: Distance from nearest well----------=------------ ------- :�___---_Distance from nearest building--------------------------------.- yl <br /> ❑ Distance to nearest lot line------------------------- --•--------------"- -' <br /> C -------------••--------------------------------------- <br /> Remodeli. and/or repairing (describe):_ ( _- - -------------- --------- ----- ---- - <br /> ---....._... - -. - �/]�- y/1 -•- --- -•-• /.------------- <br /> ----d ----- <br /> _ _ _�_yy.__�../. ry- _ _ <br /> _ _ _ _____ _ _____S____ _____ --.___.,,. _.___.____..._____._._______`l=-i 15CY---_____•c_______, -_________________•_---./____--__ ---__..-___-___ -_"- .-.___ •~r <br /> I hereby certify that I have,pr. this applicati n 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 /> 1 <br /> {Signed)_� �A�' -w--.. .1_,_ _,cit1 ` L'' ------------- -------- Owner and/or Contractor) <br /> -11 <br /> { <br /> By: ----------------- :------------------------(Title)---------------------------------------------------------------- <br /> (Plot <br /> -:--------------_-----(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-----------. ----------------------•-----.....------•- - <br /> REVIEWEDBY-------------------------------------------------- --- - ------ ---------------------------------------------------------- DATE-------- - ... <br /> BUILDING PERMIT ISSUED------------------------------------ ---- ----- -----•----------------••----------------------------- DATE------ ------••- -•- --- - <br /> -------------- <br /> Alterations and/or recommendations:----------- - ... ....... <br /> =-------------------------------------------------------------------- <br /> k ------------••----•--••---------------- ------•-----------"--•----------------------- -•------ --•---•---•-----------------------------------------•---°------._.___.._._.__...-----_..---•--------••. , <br /> FINAL INSPECTION BY-- ` 'Date----16- � ----------�--- -�---- <br /> --------------------------------------- <br /> SAN <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 Soufh-American Street 300 West Oak.Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> J <br /> ( <br /> 1 ES--9-214 115446 ATWCCD 12-54 <br /> �. 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