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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) _ 1 c/ <br /> Date Issued ---fl-f__ __ <br /> Application 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 Ordinance No. 549, i. 7 1 <br /> JOB ADDRESS AND LOCATION_----- <br /> - -D ----- <br /> --- --- ----------- --- -Owner's Name_ ------ <br /> r -- -l-�-/--�l-------- ' <br /> y--* a Phone--l <br /> Address--------------------- /- <br /> ------- <br /> --- --------- <br /> 4:1 <br /> Contractor's Name -- --- ------- Phon -�2.-� <br /> Installation will serve: Residents [B—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of living units: /---- Number of bedrooms _ Number of baths y <br /> _ --- Lot size ---- s El <br /> Water Supply: Public system r Communit s stem �w ' �/.Sr <br /> y y ❑ Private ❑ DepthYto Water Table -----___ ft. <br /> Character of soil to aidepth�of 3 feet: ISI,d ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe aiardpan r] <br /> Previous Application Made:r,Yes ❑ N'o [f New Construction: Yes E] No [�1=HA/VA: Yes [71 No E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or`cesspool permitted if public sewers available within 200 feet.) <br /> I <br /> ep is Tank: Distance from nearest well-----------------Distance�f tom foundation---:___g_',__ '_4_.Materia4-_----------------------------------------------- <br /> No. of compar#meri�s_4---------------- ---Size-------•-----=------------------Liquid depth' Capacity <br /> i5 s Field: Distance from nearest well------ ----.-.Distance from foundation-_--_- -----.Distance to nearest lot line----------------- <br /> " Number of lines------I--A-----------------------Length of each line--------------I---------------Width of trench <br /> Type of filter material-------------------------Depth of filter material-------._______-____.Total length------------------------------------------ <br /> / <br /> Seepage Pit: Dis#ante to nearest;,well _____ Distan m -fo dation----f/--------Distan;re to nearest lot line_______,__ <br /> (� Number of pits------ ---_'__------_Lining material :Size: Diameter-_-3 <br /> Depth----a�------------- ---- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------- ---_Lining material---__------___-------__- Q <br /> ❑ Size: Diameter--------'------------------------------Depth---------------------------------------------------Liquid Capacity--------------------------------- <br /> Privy: ------gals. <br /> Distance from nearest well---__------------------------------------ ------Distance from nearest buildin <br /> ❑ Distance to nearest',lot line--------- -------------------------------------•-------------------------------------------- <br /> ------------------------------------------------ <br /> Remodeling <br /> ----- <br /> Remo eling and repairing (describe)--------------------_-----__ <br /> 1 <br /> ------ <br /> --------------------------------------- <br /> --------------------------------------------- <br /> -------------------------------•--------•___.__----•-•-___••_-__-------__---•_-_--------•.---------•----_-_--__-------------_------_----_-------------------------------.---------_-----------------_--- <br /> ------------`---------------•-----_ <br /> I hereby certify that I have prepared this application and thaf'fhe wowork wiII'be done in accordance with San Joaquin County <br /> ordinances, ate laws, nd-rules and regulations of the San Joaquin Local Health District, l <br /> Si ned <br /> { g ) - <br /> + ----------------- -- -------------------------------------------------------------------(Owner and/or Contractor) <br /> BY: -- -------- = I - r/ l��E - ------------------------------•----------------(Title) I <br /> (Plot plan, showing size of to ocation of system in .rei'ation to wells, buildings, etc.,; can I;e placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----�s-R-`rJ----------- ------- ----------------- ---------------------------------------- DATE-------- `$ <br /> REVIEWED BY -------------------------- DATE <br /> BUILDINGPERMIT ISSUED -----------------=- ------ DATE <br /> Alterations and/or recommendations:------- ----------------------- <br /> ----------------- <br /> ------- <br /> ------------------------------------- ------------------------------------------------Y--, <br /> ------------------------------------------------ ------------------------------A--_,_ -----!--p --------------•------------------------------•---------------•----------------------- <br /> ---•------------------- ---•------------------ <br /> 't <br /> V 4 <br /> ------------- ------------------------------------------------------------ ALA P... ... <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 Revised 1-57 F.P.CO. <br />