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1'\O APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) fy <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 /> 1 This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LO TIO 'J --- '-°-----------------------------------•-------------------•--------------------------- <br /> :-----vq � <br /> Owner's Name , AN'' -------------------- Phone <br /> Address----_ 2' .. 4%....-- - <br /> Contractor's Name_ p ------•----------------------------------------------------------------------------------------------- <br /> " <br /> _ Phone-aE ----3 .{-�------ <br /> Installation will serve: Residence OV Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ----t__ plumber of bedrooms ---t-__- Number of baths 3----- Lot size ____ s_7+ _- t __________________________ <br /> ��// <br /> Water Supply: Public system Community system E] Private E] Depth to Water Table :_t ft. <br /> Character of soil to a depth of 3 feet: Sand�o Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeXV'Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes V 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: Distance from nearest well-----------------Distance from foundation__._--__.-__-_---.Material <br /> __._____.-__._.___-___..._.____._________.____._. <br /> No. of compartments--------------------------Size------------------------•-------Liquid depth----------------- --------Capacity-----------_--------- <br /> Disposal 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___.4'A_'_e_---_Distance fr m f undation_ (. _..Distance to nearest lot line__Z_-______.. \ <br /> Number of pits. - Linin material_ Size: Diame er--- p 2. " <br /> Lining 3C- ------------Depth ---�--------------------- �^ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------- <br /> __ ____.._____ ,) <br /> ❑ Size: Diameter. - Depth --------------------------------Liquid .. <br /> -------------------------------- -------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-___-_--______--__--__..._____............ <br /> ❑ Distance to nearest lot line-------- <br /> Remodeling <br /> ------Remodeling and/or repairing (describe) Orkkl- ---- ----•- - ...... � �"~C <br /> ------------------•--------------------------------------------•--------------------- ----•--------------------------- <br /> ... ---•--------•-----•-•---------•---------••--- -------------------------•--•----• <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, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)------� <br /> ------ --- (Owner and/or Contractor) <br /> By:---------- } <br /> ------------------------------------------------(Title)--�� <br /> (Plot plan, showing siz of lot, location of system in relation to wells, buildings, etc., can be placed on r arse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ------------------------ DATE--------- �' <br /> REVIEWED BY ------------- <br /> - ----- DATE-------------------------------------------------------------------------- <br /> UILDING PERMIT ISSUED---------------------------------- ---------------•---------------------------- --------- DATE----- ----------- i,, <br /> Alterations and/or recommendations:-------------------- __.- ''` '' r,. <br /> - ---- ----- <br /> ---------------- ------- <br /> ------------------------------------------------------------------------------------ -----------­­­------------------------------------- <br /> ........................... ------------------- <br /> ----------------------- <br /> --- ------ ----- <br /> s - � <br /> -- --- ----- -------- --------- --- -- ---- 1--------- -- - - <br /> ---------------- <br /> ------------------------------------ - - -- --------------------------------------------------- ------------ <br /> FINAL INSPECTION BY: - 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 ATWOOO 12-54 <br />