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APPLICATION FOR SANITATION PERMIT Permit t <br /> li <br /> D <br /> i <br /> CNo.'/aL3--- <br /> (Complete n Duplicate) <br /> 1�xl Date Issued .__..__-►�`6/ 3 <br /> t/ <br /> Application <br /> is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> iswith C nty Ordinance No. 549. <br /> application is made in compliance WwT u <br /> k <br /> .......... . <br /> Iff <br /> . ... ... ----- <br /> JOB ADDRESS(ANDLOC N.-i - --- ------------ <br /> Owner's Name_ ---------- --------------- -------------------------------------------- Phone--- <br /> Addres -- ---------- ------- ---- ---------- ---------------- ------- -----------------------------*--------------------------------------------------------------------------- <br /> Contractor's Name--------_--------------- ------ ------t------ ---------------------------------------- Phone--__-- - � �. <br /> Installa <br /> hone------ <br /> Installa i n will serve: Residence Apartment Hous Commercial E] Trailer Court [] Motel 0 Other <br /> Number of living units: _49- Number of bedrooms Z.2. Number of baths _61, Lot size ----- - --------------------- <br /> Water Supply: Public system E] Community system El Privatex Depth to Wafer Tabl�Q ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam Ej Clay E] Aclobg Hardpan E] <br /> Previous Application Made: Yes El No New Construction: Y!,!,KNO <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 founclafion---------------------Material----- ------------------ ---------- -------IZZZ� <br /> F1 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 <br /> rench---------------------------------- <br /> Type of filter material-------------------------Depth of filter material---------- ----------.-Total length_________._-_---.----_---__-----_----. <br /> Seeps , Pit: Distance to nearest well.._,1X_0'.___Di,ta,e f, m fou ion___-._. Distance to nearest lot line__-_- _.._ <br /> t /I _-Si e: Diameter_-.-- 1--------Depth-------.-- ------- <br /> S'p"j Number of pits----/-------------Lining mater Xe Distance from nearest well-__-------------Dista ce al- <br /> ation--------------------Lining material______-_.__-.-_-. ---------------- <br /> F] Size: Diameter------ -------------------------------Depth---------------------------------- --- ---- --------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well--------------------------------------------------Distance from nearest building------------------------------------ <br /> E-1 Distance to nearest lot line--------- -- ------------- --------------- --------------------------------------------------------------------------------------------- <br /> IL <br /> RemoApling and/or repairing {de siclbe):-------------- - ---- --- ----- ----r......... -------- --- -------6t; -- ------ <br /> ---------- <br /> I------- - ----- <br /> ­*­­4e0j6e1%-------------/_1AA_AA—n--- - <br /> - --------- <br /> ------------------------------------------------------- ----------------------------------------------------------- ------------------------------------------------------ <br /> -------------------------------------------------------------------------------------------------------------------------------------------I---------------------------------------------------------------------- --------- <br /> I hereby certify that I have prepared this application r1d that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws rules a <br /> ,p,d)reVafions of fh an oaquin Local Health District. <br /> [signed)---- ......------- ----- -- ------- - -------- ----------T------------------------------------------------- __ wrier a d ontractorl <br /> 0 lz��r <br /> By:-_----------- ------------------------------------------------------------------ ------- -- ---- <br /> (Plot plan, showing si ot. loca I o system in relation to wells, buildings, etc., can be on reverse i�e,). � <br /> • FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------------ ----�_ --------------------------------------------------- DATE-------------5E' -------97�--- <br /> REVIEWED BY-------------------------------------------------------------------------------_1 <br /> ------ -------------------------------------- DATE------------------------------------- ------ --------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------I----------------------------------------------- DATE--------------- --------------------------------------- <br /> Alterations and/or recommendations:---------------------------------------------------------------------- ----------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------- <br /> 1--------------------------------------------------------- ------ -------------------------------------------------------------------------�­-------------------------------------------------------------------- <br /> -------------------------------------------------------- --------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:------------- --------_Z---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> Date-- ----------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'nuth American Street 300 West Oak Street 132 Sycamore Street _ii4�'North "C" Street <br /> / n, C t-f I Lodi, California Manteca, California Tracy, California <br /> 0 a i ornia <br /> 2M 10-52 Revised W-21M <br />