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APPLICATION FOR SANITATION PERMIT Permit No. ...�o__. /____ <br /> (Complete in Duplicate) <br /> Date Issued ---- <br /> �Aica4ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> ,Tti s application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS A LOCATION...!__.L _I !_CQ, '"�' ;' ----------- -------------- ------------•--•---- <br /> Owner's Name ------•------------------------------------ - --- - ---•- -----=------------------ Phone--------------------------- -------- <br /> ------------------ <br /> ------- <br /> - <br /> AddressR' = <br /> Contractor's Name-------- - ----------------------------------------•------------------------------ ------------ Phone--------••-•-----------------=- <br /> Installation will serve: Residence Apartment House []",(Commercial ❑ Trailer Court ❑ /Motel ❑ Other ❑ <br /> Number of living units: _ _____ Number of•bedrooms _ LI Number of baths _J_____ Lot size ------ -- - ---______-__-_-__________ <br /> Water Supply: Public system a_ Community system ❑ Private ❑ Depth to Water Table -------- f+. <br /> Character of soil to a depth of 3 feet:- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No F,�. New Construction: Yes�No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No Septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> @per c&Tj�Distance from nearest well__________________Distance from foundation___.___.__:--------Material------------------------------------------------- <br /> ❑ No. of compartments------ -------------------Size--•-•-----------------••--------iLiquid depth--------------------------Capacity----------------------- <br /> ;. <br /> Disposal Tiield: Distance from nearest well__ --------------Distance from foundation-------------------.Distance to nearest lot line________-____-_-. <br /> Number of lines -----------------------------Length of each line = Width of trench QO <br /> Type of filter material_________________________Depth of filter material---------------__.__..Total length---------------------------------r(------ <br /> Seepa e"Pit: Distance to nearest welL)Vl &-_--Distance from foundation_.P:il>�__-______. Distance to nearest lot line___--------- <br /> Distance from nearest well-----------------Distance fro m foundation--------------------Lining material______________��........... <br /> � .Depth_ �-_____________________ <br /> 1 9 material._ <br /> Cesspool: Number of pits._..___ __.____ _ __Linin . G'.__1 __.-_-Size: Diameter_-- _______________________� <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):45 �? ._ _ __ __ ___.!... ............. . <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, Stat laws, and rules and regulations of the San Joaquin Local Health Distl•ict. <br /> r1 �� � _______Owner and/or-(Signed)------ --�-7�'-,1•-•----��-'--�"--.z-r-�-=�-----=--------------------- ------------------------------------------=----- --- ----- - I � Contractor) <br /> By:----- ---------------------------------------•------------------------------------- ----------------------- .............(Title)------------•----------•---------------------------------------- <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 ONLY <br /> APPLICATIONACCEPTED BY------ ------------------------------------------------------- DATE_ -------------- -------------------------------- <br /> REVIEWED BY------------------------ '---- -- ---- DATE--T----- <br /> BUILDING PERMIT ISSUED-------------------------- DATE------ ----- - <br /> Alterations and/or recommendationI-s:__.________._..-- <br /> ---------- -•---------- ------ ----- ---- y. . <br /> ---- <br /> -- <br /> ---- <br /> -- <br /> -.-..--. <br /> --------- -- ----- --- <br /> ---­-----------------------------------I-----------------------------------------------------------------------------------------------------------------------------_----------.--_-----------------------------------------------_-----------------------------------------­-----------------------------------------­----------------------------------------I---------------------------------------------------------------------­---------.---_--------------------------- <br /> Jf!�----)-------e- -------------------------------- <br /> FINAL INSPECTION BY: <br /> / <br /> --------------•--------------- <br /> SAN <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5-9-21A 145446 ATWOOD 12-54 <br />