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APPLICATION FOR SANITATION PERMIT Permit No. ._.��_Jr_ <br /> ,\ (Complete in Duplicate) <br /> 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 Count Ordinance <br /> r � <br /> JOB ADDRESS ANP LOCATIP- ,d- <br /> ..... <br /> ..... _-. ------ ---------------------------------------------------------_--------------------------------------------- <br /> Owner's Name. ` �... ----- - <br /> v <br /> 1/ ------------------------------------------ --------------------------- ----------- Phone------------------------------------ <br /> Address......... <br /> --•-- ............. --•--•-•------•----•---------••-----•-------•...-•-•-------•-••---••••-•-•••••-•-••----------------------------- <br /> Contractor's Name --- -•------- •. -- --- -----------------•------------------------------------------------------------- ....... Phonei.�9._b. <br /> Installation will serve: Residence J5_-ApWr1_m_e_n1 House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -----[- Number of bedrooms __`L Number-of baths . ----- Lot size -----�-__A -y---------------- <br /> Water Supply: Public system 8}—Community system [-] Private ❑ Depth to Water Table,47t. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe r pan ❑ <br /> Previous Application Made: Yes ❑ No 4_4+8w struction: Yes ❑ No �, <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sept' Ta Distance from nearest well_________________Distance from foundation__---__.-_•_------_.Material---___-_____.__.______-____._......________._.... <br /> No. of compartments----- . ----------_Size--------------------------------Liquid depth--------------------------Capacity----------------------- <br /> ispo I Field: Distance from nearest well_________________Distance from foundation--------------_-----Distance to nearest lot line................. <br /> Number of lines-------------------_---------------Length of each line___-_---_----.--.-_-_.......Width of trench.___ <br /> Type of filter material-------------------------Depth of filter material_--.----.-____-_-----Total length___--__---_-___-_-----___-__-_---___--__-_ . <br /> Seepage Pit: Distance to nearest well ..____Distance m f ndation-___-'...Distance to nearest lot line--- <br /> Number of pits..._ __._____.___Lining material_.. <br /> ---Size: Diameter_ ......... ---Depth__Z ... ..... <br /> Cesspool: <br /> Cesspool: Distance from nearest well-----------------Distance from foundation__..-_--__-.__-.-_..Lining material__.--------___-_--_-__-____--______--. \� <br /> ❑ Size: Diameter----------------------------- ----•--Depth----------•----------------------------------------Liquid Capacity------•-•----_--..-------gals. V <br /> Privy: Distance from nearest well-----------------------------------------------__Distance from nearest building----_--___._---_--____--------.-_--__-_.-. <br /> ❑ Distance to nearest lot line-------------------- <br /> Remodeling and/or repairing (describe)---------- ------------------•-•-------------------...-----•-•-----------------•=--•---•--•---•--•---••--•--•--•-----•--------••-- <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 /> (Sid -- ... ..---. --- ---------- <br /> �9ne )--- ----- ----------------------------------------------------------------------(OwwaF.ancl,Lor Contractor) <br /> By: <br /> (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 /> REVIEWEDBY---------------------------------- -- ------------------------------------------------- DATE--- - ' - ........................�,a s <br /> BUILDINGPERMIT ISSUED------------------- ---------------------------------------•--------------------------------------- DATE..................... <br /> Alterations and/or recommendations--------------- -•---- -------- --------------------------------------- <br /> ------------------------------------------------------------------------ -_--------------- -------- --...--------•--•----•---------•••---•-----••-------...-------••••--------•---•--••----•••---•-------•-•----•---••----- <br /> -----------------------------------------------------_----------­------- --------------------------------------------•-..............•.................................................................................. <br /> ----- ------------------------------------- -----------------------•----------------------------------- -----...--------••----••---•--•-•-------...._.._......-•--.._...••-- <br /> ------------------ ------------ ---------------------------------------------- ...................................................... -- ..................................................... <br /> FINAL INSPECTION BY:..-.�/j ��� �' ^��,......__ Date-------�----- ------------ <br /> - � <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 /> ES-9-2M 145446 ATWOOD 12-54 <br />