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APPLICATION FOR SANITATION PERMIT Permit No. <br /> {Complete in Duplicate) <br /> Date Issued - <br /> -- <br /> A <br /> �plica�lion is hereby m to the an Joaquin Loca! Health� District for a permit to construct and install the work herein descrIbed. <br /> This <br /> : <br /> application is made in'compliance with County Ordinance No. 5 r. <br /> JOB ADDRESS AND CP,TIO ---f------ ------- --- --------------- <br /> Owner's Name— <br /> --------------- -------- --- ----- --- --------------------------- Phone---- -------------------------- <br /> Address--------- <br /> ----------- -------- ----------- ------------------------------------------ <br /> . .- 2 -Vf 4 <br /> ---------------------I------- 2-VA4 <br /> ----------- -------------------- <br /> Contractor's Name.-----.. -------- -------------------- Phon <br /> Installation will serve: Residence Rn-,-?'C-partment House El Commercial E] Trailer Court E] Motel E] Other D <br /> Number of livingunits: /----- Number of bedrooms __"�_ umber of baths ---/-_ Lot size -------<-----t-4i<--;------ ------- <br /> Water Supply: Public sys 11 Im 54�omrQnify system D Private 0 Depth to Water Table ft. I <br /> Character of soil to a depf ti�of 3 feet: Sand E] Gravel E] Sandy Loam El Clay Loam Clay El Adobe&_AVadpo"n E] <br /> Previous Application Made:! Yes n No Ei­fisw Construction: Yes ❑ No <br /> TYPE OF INSTALLATION IAND SPECIFICATIONS: <br /> (No septic tank or Aspool permitted if-public sewer is available within 200 feet.) <br /> Septic Tank: Distancl, from nearest well------------------Distance from foundation--------------------Material-----------------1----------------------I-------- <br /> No. of ompartments------- ------I----------- Size_....----1!�-------------------Liquid depth------------ --- ---------Capacity-------------- .-------- <br /> isposal <br /> apacity----------------------- <br /> Asposal Field- Distance frorni nearest Distance from foundation---C 4M-------Distance to nearest lot line--/O....... <br /> Numbed <br /> of lines--------- Length of each line-------__?457_!�-.----.Width of trench---- <br /> riline----------------- <br /> - ---------------- <br /> , filter 0 <br /> Type o material---------/,�y__'Tofal length--------9- ------------------------ <br /> S 3eepa a Pr;'f 6 w- 11 -Distance to nearest lot line------- ------- <br /> eepa -I Distance to neare"st, e -- Distance from foundation---_.-.._____--.__:Distance <br /> it" of pits---------------------Lining material----=---------------- Size: Diameter----------------- -----Depth--- ---------------------------- <br /> C C ssr)ool. <br /> sspool: Distanct from nearest well-----------------Distance from foundation--------------------Lining material_____--.-.--.-..__-._-----__------- <br /> ❑ <br /> Size: Di'bmeter--------------------------- Depth----- -------------------------- -----------------Liquid Capacity--------------------------'gals. <br /> Privy: Distanclip ------- <br /> v from nearest well-------------------------------------------------Distance from nearest building----.---_-----.-----_-_--_.__ <br /> ----------------- <br /> Distance to nearest lot line----------------------------------------------- ---------- <br /> Remodeling and/or repairing (describe):----------------- -- ------- -- ----- -------------......../--------- --------------- --­--------------- <br /> ----------------------------------------0------------ I- -— :- _r - <br /> ....... ---------- ........ <br /> -------qA <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I <br /> F ----------------------- <br /> --------------------------------------------- ------------------------------------------------------------------------------------------------------- -------------------------------------- <br /> I hereby certify that 1.,have prepared this application and that the work will-6e clone in accordance with San Joaquin County <br /> ordinances, law an r and re ulations of th San Joaquin Local Health District. <br /> (Signed)_-, ........ - ------ - ----- ------ -------------------------------------------------- -------- - ..contractor) <br /> - <br /> -- - -------------------------------------- <br /> By:...... .... -- - ------- ---------------(Ti -----I:------- <br /> (Plot <br /> I-------- <br /> (Plot plan, sh ' ing size of I'it, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTEDi ,BY_R--------------------- -------- -------------------- --------------------------------------.- DATE--;;,.--.--.. <br /> .;:_ ---------------------------------------------- <br /> REVIEWEDBY--------- ----- --1% --------- ------------------------------------------------------ <br /> ------- - --- .- DATE__.__V`- ------------------------------- <br /> ------------ <br /> BUILDING PERMIT ISSUED----------------------- ----------------------------------------------------------------------------- DATE.-- ------VN----------------------------------- <br /> Alterations and/or recommendations:. ------------------------------- -------------------------------------------------------------------------------- ------I-------------- <br /> --- <br /> ------------------------------------------------------------------------------------------------------------------­­­---------------- --Ill <br /> ------------------------------------------ <br /> ---------------------------------------------------------------- ------- ---- ---------- -------------- --------------------------- ---------- ------------------------------------------------------------------------- <br /> ---------------------------- ....... ------------------------------------------------------- -------------------------------------------------- ------------- ------------ ------------------------------4:------- <br /> FINAL INSPECTION BYI <br /> --------------- _- ---------- 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 j <br /> E5-9-2M 145446 ATWOOD 12-54 <br />