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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued <br /> IV <br /> gA <br /> plica-i,ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This <br /> application is made in compliance with County Ordinance No. 549, <br /> JOB ADDRESS A LOCATION--&-1- 4L---- <br /> A <br /> A-Y-4 <br /> ---- ------ Phone----------------------------------- <br /> Owner's Name----- -- ...... .... - ------------------------- ----------------- <br /> Address------------ --------- --------- ---- -- - -- ----- ----- ------------------------------------------------- --------------------------------------------------- <br /> - -------- Phonej <br /> Contractor's Name------ -- ----� I---------------------------------------- <br /> Installation will serve: Residence 0 Apartment House 0 Commercial EJ Tra�er t ❑ Potel [3 Othergl_,�o <br /> �aour�p - <br /> Number of living units: Number of bedrooms -------- Number of baths),iTp Lot size --- -------------------------------------------- <br /> Water Supply: Public system ❑ Community system El Private [If- Depth to Water Table __---- ff. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam El Clay..El AdobeO, Hardpan 0 <br /> Previous Application Made: Yes [3 No N- New Construction: Yes DS-No E] -.1 <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_____0------ Distance fjorn foundation---/0..........Mixferial--- ------- <br /> Qe- i depth-----f <br /> No. of compartments---- ----_-well__.___ <br /> 1 �"4----�.6. Liquid -A.............Capacity <br /> , -------- <br /> Disposal Field: Distance from nearest well_X __Distance from foundation----/A----------Distance to nearest ]of lineT 4kAk_-— <br /> 1rX_ <br /> ----------- <br /> Number of lines____________ _r2------------------Length of each line________ of trench------z9-44-------------- ...... <br /> Type of filter material------ <br /> �Ffr!,LtQ------Depth of filter material......./I--------Total length--------A-Z ------------------- <br /> Seepage Pit: Distance to nearest well.195L"___ ----Distancefrpm fourLdation-.-Z".--"--.Disfanc7 to nearest lot line, <br /> IN- Number of pits._.____________Lining rnateriaLoi�... Diameter--------4-A-------Depth_____.1 -__ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------- -----Lining material_._.____---_______.____------__--___ <br /> ❑ <br /> aterial-------------------------- --------- <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 /> e�9 <br /> Remodeling and/or repairing (describe):----- A--- --------------- -------- ............... ---------------------------------------------------------------------- <br /> ------------------------------------------------------------------------ -------- -- - -- -- ------------------------------------------------------------------ <br /> ---------------------- -------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- ------I------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done%1n accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)...... -------- ------- ----------------------------------------------------------- -- --------(Owner and/or Contractor) <br /> By:--- _4(4Z4e.;:_;e - ----------------------------------(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 /> APPLICATION ACCEPTED BY- ------------- --- - - --- ------ ---- -- ---------------------------------------- DATE----- <br /> r------------------------------------------------------ <br /> REVIEWEDBY------------------------------ ------- -- ----------------------------------------------------------------------------------- DATE__Z_X--------------------------------------------____- <br /> BUILDING PERMIT ISSUED------------ ------------------------------------------------------------------------------------- DATE------- ----------------------------------._...----•----• <br /> Alterations and/or recommendations:------------ ---- - ------- - --- ------- ---------------------------------------------------------:!T'------_-----7------------------------------- <br /> -------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------- --------------------------- ------ ------- ------ -----------------1-----------------I---------------------------------------- ----------- ---------------------------------------- <br /> ----------------------------------------------------------------------------- -- -------------------- --------------------------------------------------------------------------------------- -------------------------------- <br /> --------------------------------------- --------------- ---------- ----------------------- --------------------------------------•-------------------- ---------------------------------------------- <br /> FINAL INSPECTION ---------------- --- - --- --------- Date....... ,a-_-..-------- ----------------------------- <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 145446 ATWDZD <br />