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w <br /> (_ 1 <br /> APPLICATION FOR SANITATION PERMIT Permit No. --!. <br /> (Complete in Duplicate) Date Issued <br /> t 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 Coun y Ordinance Na. 544. <br /> - ----------------------- --�' -------- <br /> JOB ADDRESS AND LOCATION----,( - - ---- ------ -------- � ''� <br /> Owner's Name----------------- o`�- i'�c yt- --j-- ------------ .... -..__ - ------------- -------- ---------- Phone------------------------------------ <br /> Address--------------------------- � r / ----- Ca - �? <br /> Contractor's Name-----------------------_-- �ent <br /> --------------------•--•--------------------------- --------------•-----•----------------------- Phone----------------------------------- <br /> Installation will serve:- Residence House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ yOther ❑ <br /> Number of living units: __/___ Number of bedrooms 5__ Number of baths _Z Lot size ___m __' ._�_ � <br /> Water Supply: Public system El Community system F1 Private [Depth to Water Table /0-'- ft_C�__•_fl_�r�%) <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravei ❑ Sandy LoamClay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes,❑ No ® New Construction: YesIdo ❑ _.. ._. <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-_.S �- Distance from fours ation_/4_____________Maferial_CdH-r --�._________ <br /> No. of compartments-- - --�---- ......Size_��_ .rJ_ __ .---Liquid depth-------1�_'G---------------Capacity----- ((�-.. <br /> Disposal Field: Distance from nearest well_ZQ_..___-_Distance from foundation---- ..._....Distance to nearest lot line-7-.> ------- <br /> Number of lines_____:5.......... Length of each line_____ _.-- ---------- --------.Width of trench_-Zj <br /> _ -..______.______- <br /> Type of filter material.__c5✓.�'4 Depth of filter material____./i -_.__.___._Total length �_____________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-____._.________ <br /> ❑ Number of pits---------------------Lining material---------------- -Size: Diameter----•------------- ----Depth------------------- ---_•--- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation.------------------ Lining material--------------._____._____________.__ <br /> ❑ Size: Diameter----------- ------------------Depth--------------------------- ------------Liquid Capacity-.--------------------------gals. <br /> Privy: Distance from nearest well -----------------------------------------Distance from nearest building-------------__-----------------------_--. <br /> ❑ Disfiance to nearest iat'Fine = <br /> r <br /> Remodeling and/or rep6iring (describe):------------------ ------------------- --------•---------------------- -••---`-- <br /> -----------•------•--•------------------------------------------•----------•--•------------------------------------------------------------ --------•----- <br />' -------- F----•---------------- ---- -••--------------•---------------------------•--•----------------------------------•----•-••-----------------------------------------•-•-------- <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 /> (Signed)-- <br /> By:----------------- <br /> )By:--------------------------------------------------------------•------:-----------------------------------------------------------•(rifle)--------- ------------------------------------------------------ <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 NLY <br /> APPLICATION ACCEPTED BY---- ---- --- • •• - ------ DATE-- :L - �------------- <br /> - -- - - - - - -- <br /> REVIEWED BY--------------------------------------------- -------------------- ---------------------------------------------------------- DATE------------------------------- <br /> ---------------------------- <br /> BUI LD1 NG PERMIT ISSUED-------------------------------------------­­- •-------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations-------- --------- ----------------------------- ----------------------- ---------------------------------------------------. <br /> t ------------------------------- --------------------------------- -------------------- ---•- ---------------------•-------- . <br /> -------•-------------------- -----------------•-------------------------------------- ---------------------------------------------------------------------------------------` -•--- ••-•--••------- <br /> "----------------------------------------------•------------ --------------------------- ------------- -----------------------------•-- ----Y-•---------------------------------- <br /> FINAL FNSPECTION BY... '. ! -------------- Date_ ... f I � ' <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .. 5 <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 /> I45446 ATW000 12-54 <br />