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APPLICATION FOR SANITATION PERMIT Permit No. _ 3... <br /> 1p <br /> (Complete in Duplicate) Date 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 /> JOB ADDRESS AND L CATION_ ____ --- -�3 ------------------ <br /> o- <br /> �' Phone------------------ <br /> Owner s Name-------•----- L� <br /> Address-------- ----------------- ------- -- ------ -----------------------------------••---------------------------•---------------------...... -_---------------- <br /> Contractor's Name <br /> ------------- -----------------------------------------:•---------•------- Phone- 4A:�Ie <br /> Installation will serve: Residence partme t House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _/__-- Number of bedrooms _�____ Number of baths of size __/__�_,�__�______ 1 ------------------ <br /> Water Supply: Public system'O�Community system ❑ Private ❑ Depth to Water Table ko ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay..Loam ❑ ClayE] Adobe OL Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ® New Construction: Yes D�J_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: istanceefro�m nearest well------------------Distance from foundation--------------------Material--------------------------------_---------------- <br /> ❑ o. of compartments------------- ------Size-------------------------------.Liquid depth--------------------------Capacity------ ---------------- <br /> Disposal Field' distance from nearest well................:Distance from foundation--------------------Distance to nearest lot line----------- <br /> ❑ of fines Length of each line Width of trench <br /> 7 Type of filter material------------------.__-------Depth of filter material-----------------------Total length------------------------------------------ <br /> Seep.age <br /> --.---------------.----------------------Seepage Pit: Distance to nearest well--- Distance r m foundation--- nearest lot line_-_ Q-_�__ <br /> Number of pits------_-------------Lining material -Size: Diameter____- 3.._?�Depth_���- 7t.-____.---------- <br /> Cesspool: Distance from nearest well---------------.-Distance from foundation--------.-------.---Lining material__._____.._.--__._________-__-._____. <br /> Size: Diameter--------------- --------------- '- -.Depth--- - ------------------Liquid Capacity_-----_ ------------------ <br /> Privy: Distance from nearest well "_=- --------------------------------Distance from nearest building------------------------------------------ <br /> nDistance to nearest lot'line_-'-` -------------.` -- -------------- --------------------------------------------------------------•---------------- <br /> Remodelingand/or repairing (describe)---------- -----------------•--------------•-•-------•-•---------------------------••-------------------------------------------------------•-•--------- �3 <br /> --- --------- -------------•---•----------------•---------- ---------------------------------------------••------------------------------•---------------•--------------------------- <br /> I hereby certifyhat I have prepared this application and that the work will 6e done in accordance with San Joaquin County <br /> ordinances, St S. and rules and re_gu�laat�ions of the San Joaquin Local Health District. <br /> {Signe ---- --- ---- --- ---------------- ------------ <br /> p__- -- -----------------------(Own r and/or Contractor) <br /> B ... - ------- {Title) .G' <br /> y• -- ------ -- -- <br /> (Plot plan, s owing size of lot, location of system in relation to wells, 6uildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY------------- ------------- --- ------ ------------ ---------- ----------------------------- DATE-------------------------------------- ----------------- <br /> REVIEWED BY ------------------------------------ ------ --- ---- DATE <br /> DATE ..... <br /> BUILDING PERMIT ISSUED------------ ------ - -------------- ------------------------ - <br /> Alterations and/or recommendations-------- ---------------- ---------------- -------•-•--------------------------------------------------.------- --�Ir <br /> ------------ <br /> .--•-- ------------- --- --- --- ------------- <br /> ------------------------------------- <br /> ....: <br /> as-_-gym- ---•------------------------------------------ - ------------------------- --------------------------------- <br /> ------------------ ------------------------------I----------------------------­ <br /> FINAL INSPECTION BY:._1CZS-_,:----- _-------------------=-------- 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 /> EE-4-2M 145446 ATWOOD 12-54 <br />