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1,q\ APPLICATION FOR SANITATION PERMIT Permit No. ...T._ ... ...... <br /> 0 .. <br /> (Complete in Duplicate) (p <br /> Date Issued,.. ....... .S <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to co struct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> 1 <br /> -­ --------------------------------------- <br /> JOB ADDRESS CATION.} � .� = ............. ............- ------------ <br /> Owner's Na Cst,��1�C-'v '�a.- ----------------- -------------------------------------------- Phone----------------------------------- <br /> Address----- ----------- ----• i;..---------•----------------------------------------------------•-...— <br /> .....A <br /> Name Phone� .�C <br /> ���"Z�--'`"" <br /> Installation will serve: Residence ant House ❑ Commercial ❑ Trailer Court ❑ M,,ogtel ❑ Other ❑ <br /> Number of living units: _ -_- Number of bedrooms .Number of baths ---I... Lot size ---- V______. __ZU_�............... <br /> Water Supply: Public system Community system ❑""-Private J-De-pth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ar pan ❑ <br /> Previous Application Made: Yes ❑ No 4--New Construction: Yes ❑ No E _ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sept Tank: Distance from nearest well------------------Distance from foundation----------..........Material----------------------------------------- -__--. <br /> 1 No. of compartments---- ----------- ---------Size----------------------•--------Liquid depth--------------------------Capacity....................... <br /> Disposal Field: Distance from nearest wellJ� &---_ , <br /> Distance from foundation.. ___..Distance to nearest lot line...` ` <br /> - . . ......... <br /> Number of lines_________ _________________ ___Length of each line----�__C}_01-_-`_--.___--.Width of trench <br /> Type of filter material---,/__-�___�-__-_-_-__-Depth of filter material---�._�.�r.r.Total length_.-. � "____--___---_— <br /> Seepage Pit: Distance to nearest well_ /{ if-_-1-__Distance Lorn fou dation__ &.......Distance to nearest lot line AD..... <br /> 91---1 Number of its.__ __Linin material___ j�.• t -Size: Diameter-3 :._..._...Depth-__-JW—/ ______________ <br /> p ------- 9 <br /> Cesspool: Distance from nearest"well------------_....Distance from foundation--------------------Lining material__ _-_--______---_-----_--_-____.. <br /> ❑ - -• v <br /> Size: Diameter---- ------------ -------_----_--Depth----•-----------------------------------------------Liquid Capacity--------- ---------------•-gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-____-_-__-_-._-_----_---------__-__-_---. <br /> ❑ Distance to nearest lot line--------- ------------------------------------------------------------------------------------------•---------------------------------------- <br /> Remodeling and/or repairing (describe):----------------------- ------------------------------------•----------•-----------•------•---------•=......---•-•...................................... <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, la , an u s and ulations of t San Joaquin Local Health District. <br /> (Signed)- ------------------- ------------------------------ contractor) <br /> By: - - - - - - (T�+le) `�''� --------------- <br /> y• = <br /> (Plot plan, showing sjze of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY------------ ------- -- ------- ----------- ---------------------------------------------- DATE--- --- -------------------------------------------- <br /> REVIEWEDBY------------------------------------------- --------- -------------------------------------------------------------------- DATE.....--- ------ <br /> BUILDING PERMIT ISSUED ----------- ---- - DATE <br /> Alterations and/or recommendations------------------- ---- -- -- . <br /> . Nf------------------------ <br /> ----------------------------------------------- ................ ----......----------------•------------------•---•---•---•-----•...---------....------------. <br /> ----------------------------------------------------------------- --------------------------- --------------------- ---•------------...-------------------------_....-----------------------------•----------••---------•-----. <br /> ---------------- ------------------------------------------------------------------------------------------------------------------ -------------------------------------- ................................................... <br /> rr- <br /> FINALINSPECTION BY:-----------4- ------------------------- 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 /> ES-9-2M 145446 ATWOOD 12-54 <br />