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lee <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <br /> Applica-l'icin is hereby made to the San Joaquin' Local Health District for a permit to construct and install the work herein describe <br /> This application is made in compliance with County Ordinance No. 549. <br /> It <br /> JOB ADDRESS AND L(),PATION, .,7 01Z.;k W t y-jo-�P_ -r-- -,-/,--- <br /> a .K. -------- - __ 11one------------------------------------ <br /> ---------- 3 -_ <br /> Owner's Name.. - -- -—------- <br /> Address---------------------------------- <br /> -------- . . . . .. ............ <br /> Contractor's Name-------------------------------__----------------- ----------------- Phone_......-------------------------- <br /> Installation will serve: Residence El Apartment House ��Commercial ----Tr_a_i_Ie_r__Cour_f__E1-----Motel E] Other El <br /> ------------ ---- ---- ---- -------- - ---- -_ -, /11 1 <br /> Number of living units: _k--- Number of bedrooms A--- Number of baths _J�ae--- Lot'size ........ <br /> Water Supply; Public system E] Community system E] Private �th to Water Table 499---- ff. <br /> Character of sail to a depth of 3 feet: Sand E]..,Gravel [] Sandy Loam 0---c-11—Y Loam [:] Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes E] No W1_7New Construction: Yes g?'fVo E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> !I�fic-'fa-nk 6�r cesspoo FGiffeW:j_fTa6Iic sewtr'ii <br /> aV711­b_eF1wi4�i -2efp 4 j <br /> Distance <br /> compartments----------- <br /> sfance from nearest well_________________- Distance from foundation---------------_---Material--------------- ------------------------------ <br /> El No. of compartments--------------------------Size--------------------------------Liquid depth,-------------------------Capacity---------------- ----- <br /> Disposal <br /> epfh---------_--------------Capacity----------------------- <br /> Disposal Field: Distance from nearest weII_S�`1ry1-_1*t1sfance from foundafion./A-------.�_<Disfance to nearest lot line---t--------t_ <br /> or Length of each line...... --------------Width of french-----jo.,,v <br /> Number I lines------ --- ------------------ <br /> Typeor <br /> T filter maferial__��, A�G&,_.Depfh of Pilfer material-----J.? ..-__.Total length-----ZO------------------------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------:------Distance to nearest lot line-------:--------- <br /> F1 Number of pits......................Lining material-------- - ------._-.Size: Diameter-----------------------Depth.-..--.----- ------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-- --------------------- -------------- <br /> F1 Size: Diameter------------- ------------------------Depth------------ ---------------- -- - -----------------Liquid Capacity----------------------------gals.gals. <br /> Privy: Distance from nearest well________________________-----_------__._._-_____Distance from nearest building____.-______-__--_-______------------------ <br /> ,ty- ------------- ---------ga, <br /> -------- ---- <br /> ❑ <br /> Distance to nearest lot Iine----------------------------------------------------------------------- ----------------------------------------------- <br /> ------------------- <br /> A <br /> a; ......... 0-, <br /> 7�, <br /> Rem(ideiing,and/o repair,g describe):-_-- jr <br /> ---------- -------­------------ <br /> :�p <br /> _4� 4' <br /> -------7 .....).......ZL ------- - - - -- -- ------- -- --- <br /> _P,4__e-A--------ki. ------- <br /> �_Z <br /> —A V <br /> �_ ery_s------ —------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ---------------------------------- ------------------ ------------------------- ---------------------------------------------------------------------------------------------------------*--------------------------------- <br /> I hereby certifyt at I hav prepared f application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State s, <br /> a d r s and re a ions of the San Joa uin Local Health District. <br /> (Signed)-------------------------e------ ------ <br /> - - ---------- --- --- --- - --- --------- ------------- <br /> V_Owner a�n d 7 <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 /> 'EIRARYENT <br /> _ NLY <br /> APPLICATION ACCEPTED BY., ------ ------------ DATE--- <br /> REVIEWEDBY--------------------------------------------- -----------------------­ ---------- --- ---------------------------------- DATE------------------------------------------------------------ <br /> BUILDING PERMIT ISSUED_--------------------------------------------------------------------------------------------------- DATE------------------------- ----------------------------------- <br /> Alterations and/or recommendations:------------ - -----_ - _--- ------ - ------------------------- ---------- ------------------_--------------------- <br /> ------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------- ---------------- ------------------------------------------------------------------------------- <br /> ---------------------------I--------------------------I---------------­............ ---------------- ------­-------------------------- --------------------------------------------------------------------------....... <br /> ---------------------------------------------------------------------------- ---------------------------------------------------------------------- ---------------------------------------- -------------------- <br /> ---------------------------------------------------- --- -------------------------------------------------------------------- ----------------- ------ ------------------------------- ------------------------------------- <br /> FINAL INSPECTION BY:---------- V<�--------------------------- Date----- <br /> -----I--- ------- .....t�_7--------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South Ameritan 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-S4 <br />