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o S <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) �- <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 /> This application is made in compliance with County Or nce No. 549. <br /> JOB ADDRESS AND LOCATION) <br /> Owner's Name------------- �5. _•..- -�--- -----�j--- ------------- ------------ ---------- Phone------------------------------------ <br /> Address XL -�..-- -'--�.- �--/ ' <br /> Contractor's Name-------------------- - --- ------------y�:( <br /> --------------- Phone-----•---------------------•------- <br /> Installation will serve: Residence [?'Apartment House ❑ Commercial ❑ Trailer Court ❑ /Motel Other El <br /> Number of living units: :._._ Number of bedrooms --2--Number of baths _/___ Lot size _____!___ • <br /> -------------- <br /> ----------_----------- <br /> Water Supply: Public system [ICommunity system ❑ Private Depth to Water Table /41--i ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam lay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No PNew Construction: Yes R-1101-0 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public seyrer is available within 200 feet.) <br /> Se tic T k: Distance from nearest well <br /> 0 Distance from founda ',,n/d. -- --- <br /> p A- �/ Material _ <br /> _ No of comps-rfinents - Size___=fit_ __ _ iquid—depth"" '_.--.---.Capacity_'. ' <br /> Disposal Field: Distance from nearest well-_24OV._._._Dlstance from foundation-_/o__- istance to nearest lot line--- ----._--_ <br /> 5K Number of lines------------- --y_� Length of each line___.__.___ _ Width of trench____ __,f - �________________ <br /> Type of filter material___ - ��.rr�� <br /> yp r�- f-S..`Depth of filter material --__�1S ---------Total length---.--- --®-------------------------- <br /> Seepage Pit: Distance to nearest well--------------_-------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> r- F <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 /> ❑ Distance to nearest lot <br /> li�ne�-----------------------------•---------------------------------.---_-_. _ <br /> l-------- ------ <br /> ------ -1.... •. -� ---------- --------- --- <br /> �----- -e � <br /> ---------- -- - -- �-5 ------V-�- <br /> --------- --;p------�----r <br /> ----------- -'----Ask------ �' '' a =��' '�y ---•-•------------------------------------------- <br /> I hereby certify that 1 have prepared this application and that the work will be lone in acc rdance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)------- ---------- -----or---- (Owner and/or Contractor) <br /> --- --------------------------- Title <br /> (Plot plan, showing si of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> APPLICATION ;ACCEPTED BY---- ._ - _.__±: <br /> -' ' -- -'-'- '-'- - - - --- --- ----- -- DATE-----.��-=- =-� - ---��-------------- -- <br /> REVIEWEDBY-------- ----------------- ----------------------- ---------- ----------------- ---------------------------------•---•-------- DATE---- ----------------- <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------------- ---- ------------------------------- DATE--------------------•----- <br /> ------------------------------ <br /> Alterationsand/or recommendations----------- ------------------------------------•----------•------------------------------------•--•-----------------------•-------------•--------------------- <br /> •------•--•------•---•----•------•-------•--- -----•---- -•------------------------------ --------- ------•-•------••-----------------------------------•---•-----------------•--------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----- ------- ­----------------------- <br /> ----------------------------;_------------------ <br /> ----------------••---.----------------------------•--------------------- ------- ------ ---'---- ---'------- ----------------•---•---•-•----•-•-- ----------------------------------•----------••--•- -••--------------------------------------- <br /> (,Zc_ w �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 /> 17S-9-2M 145446 ATWOOU 12.54 <br /> pj <br />