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APPLICATION FO►_ jANITATION PERMIT Permit- No. .2`.a-./.. <br /> (Complete in Duplicate) � <br /> Data 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 LOCATION----------- ---A11 8-.W,---afT acy._._Qn_..Q�d._i#�flHIghwa ---- _turn-_.1e_ft----at <br /> Owner's Name-D,-___�`�,-__H�_�knipythe street car and 3rd house on rt. <br /> ------------------------------------------------ --------------------------------- --- Phone---TQ---5.��0Z...... <br /> Address. Rt. 1, Box 69 <br /> Contractor's Name----------------------------------Delta_ Phone. HQ,-- rIZ6. <br /> Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: 2__-- Number of bedrooms 3_____ Number of baths _fl---- Lot size ----3----caC?"_A-_______________________-________-__ <br /> Water Supply: Public system ❑ Community system ❑ Private ® Depth to Water Table ---aO ft. <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 E2: 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 /> Septic Tank: Distance from nearest well__;______________Distance from foundation-------------------Material------------------------------------------------- <br /> El No. of compartments--------------------------Size--••---------------------------Liquid depth----------- --------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line________.___.._-. <br /> E❑ Number of lines-----------------------------------Length of each line-----------------------.------.Width of trench----------------- -----•----------- <br /> Type of filter material-------------------------Depth of filter material------------_---------Total length----------------------------------_---.--- M <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------._.---.Distance to nearest lot line__.___________.__ ( 1 <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---.----------.__..----Depth--------------------.------------ C <br /> Cesspool: Distance from nearest well----Q-1_.._-Distance from foundation__1Q1.......... material____CQMent--brlck� <br /> [ Size: Qiameter �� Deptht-------------------------------------Liquid Capacity- - - <br /> Priv Distance from nearest well------- ----_ Distance from nearest building <br /> -----. <br /> ❑Y ------ ---------- ------------------ ------- ------------ C-13 <br /> Distance to nearest lot line --------------------------•---------------------------------------------------------- <br /> Remodeling and/or repairing (descriUe)____...... T _all �s___ t ._�.1 ver-_.____f4T1--- �fp___j1----- _ .-r1k.-Wb P <br /> --------------------------------------------------------------------------------- <br /> Ol) __-- ta'I11T103'�� �r,cx <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 <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> {Si ned Delta <br /> 9 - - - ------------------------------••------------------------------- ----------------------------------------------------------------------.(Owner and/or Contractor) <br /> By=--------------------------P-%, WA--------•- ••---------------------- ------------------------------------------------- -----(Title)- �*'Ch1. ---------------- ------ <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 /> APPLICATION ACCEPTED BY--------- ------------------------------------------- DATE--------------------(( � --------•------- - <br /> REVIEWED BY �•,.. DATE =ff1 ---------•-------------•------- <br /> BUILDING PERMIT ISSUED - � ;;?---------------•---------------------- DATE------------- <br /> Alterationsand/or recommendations:------ ------------------------------------------------------_-_------•--•-----------------------•-••--------....----------••---------------------------•-------- <br /> ----------------------------------------------------------------------------------------------------------------------•---•------------------------------------------------------------------------------•-------------------- <br /> --------------------------------------•-------------------------- ------ --------------------------------------------------- .------ --------------•------------------------------------- <br /> ------------------------- --------------------------------------------------•----------------------------------------------•---••--------------- <br /> FINAL INSPECTION BY-------------- --- ----- Date__.--_---; !-I. <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 /> E5-9-2M 145446 ATw000 12-54 <br />