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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate), Date Issue-d <br /> Applical,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. S49. <br /> Z —------------------- ---------I------- -- --- --- --- <br /> ------------- ----------&z�---------- <br /> JOB ADDRESS ANDiLOCATION ­­--- ---------------�_?__kh <br /> Owner's Name---------------- <br /> ------- ....... ------------------i-- ---- ........ Phone----------------------------- <br /> -----------------------T-------------------------------------------------------------------------------- <br /> Address...-------------------------- -- ---- ------ <br /> Contractor's Name.--------------------------------------- ---------------------------------------------------------------__--------- Phone-.------------------------------.. <br /> Installation will serve: Residence E] Apartment House [_1 Commercial Ej Trailer Court [] Motel I–] Other E] <br /> Number of living units: --- Number of bedroorns-3, ----- Number of baths /------ Lot size ------------�K_ ----------- <br /> Water Supply: Public system Community system 0 Privat epth to Water Table -------- ft. <br /> q.�K <br /> Character of soil to a depth of 3 feet:- Sand E] Gravel E] Sawy Loam E] Clay Loam E] Clay E] AdobHardpan [I <br /> Previous Application'Made: Ye-s;K No E] New Construction: YeLrK No E] <br /> TYPE OF INSTALLATION AND No <br /> (NAeptic fl or cesspool permitted if public sewer is available within 200 feet.) <br /> i I IVIdT <br /> Septic'Tank: Distance from nearest well-- Distance from foundation--/d----------- oria L. ---------- <br /> 4 r <br /> - ___.U�uid depth-----e/---1, -----capacity--------9% <br /> Na. of compartments-____-_ <br /> D;sp Distance from ------------ Distance from foun,clafgon ------ --_---t- <br /> -----f- <br /> osal Field: nearest well. .... _____W�i' Distance to nearest lot 66 <br /> Length of each line-1)Ae- ---.Width of trench.___...__.__ <br /> Number of lines------------ ------- i---A- Z <br /> or - 3 __ .Depth -------4-----------Total length---------- 1 ---------- <br /> Type T filter material---, - of filter material <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------:Distance to nearest lot line--.--..-_--._____ <br /> Number of pits----------------------Lining material-----------------------Size: Diameter------.------.--------.Depth--------------------------------- <br /> Cesspool: <br /> epth------------- ------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation... ................Lining material-----------------------------------_- �1\ <br /> El Size: Diameter----------- ---------------- - -------Depth--------------------- ---- ----------------Liquid Capacity-.-.------------------------gals. <br /> Privy: Distance from nearest well...... ------------------ -------------Distance from nearest building----------------------------------------- <br /> ElDistance to nearest lot line--------- ------------------- ----------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing {describe----------- ------1`1------ ---------- ----------------- 3_- -­------------------------------------------------- <br /> ------------------------------------------------------------------------ -------- -- - --- --------------- -------- -----------------------------------11----------------- ------ <br /> f <br /> --------------I---------------------------------------------------------------------------- - ---- ----------------------_ -----------------------------------------------------• <br /> ---------------------------------------- <br /> -- - -- ------------ <br /> - I -�_ _ <br /> ------------ <br /> ou�......... <br /> - <br /> -----------------------------------------------------------------------------------I----------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepared this application 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 /> (Signed)---- -•---_; A ---l-t�--------------------- -------- --- (Owner and-/or Contractor) <br /> By:......... --------I-------------------------------------------------------------------------- -----------------------------------(Title)--------- ------------------------ --------------------------- <br /> I <br /> (Plot plan, showing Size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> A <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY--- - ----------------------------------------------------------------- DATE----- ----------------------------------------------------- <br /> REVIEWED BY---- -( <br /> - ------------------------ -------- <br /> - ----- --- ----------------------------- _--------- DATE.-----------------•--------------------------------•------- <br /> ............. <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------- ---------------------------------- <br /> Alterationsand/or recommendations---------------------- ---- ---------------------------------------------------------------------------------•--•--------------------------------..--...------ <br /> f <br /> --------------------------------------------I------ <br /> ---------------------------------------- .........I------------------------------------------------ ------------------------------------------------------------------------------- <br /> ----------------------- <br /> ---------------------- --------------------- -------------------------------------- ------------------------- --------------------------------------------------------------------------------------- <br /> 0 P -----------------------------•-•------------`---------------------- <br /> ------------------------------------------------------------------------- -------------------- ----w ------------------------------- ---------*------------- <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 /> E5-9-201 145446 ATWCU- 12-54 <br />