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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) L Date Issued <br /> -A <br /> Applic, �i h reby 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 compliant 11 th County Ordinance No. S49. <br /> JOB ADDRESS AND LiF��TION -- ------------ - ----------------- - ----- <br /> ---------------------- ---- --------------------- <br /> f . <br /> Owner's Name-----------1=-�_ _ 4-------- ------------------------ - -------------- Phone--------------- --------- <br /> AN' <br /> Address....................... -- -------------_-_--------- ...... <br /> Contractor's Name...------• <br /> ------------ ------------------------------------------------------------ ----- ----------------------------------------------- Phone--------------- --------_-------- <br /> Installation will serve: Residence Apartment House E] Commercial [] Trai I ler Court [] Motel E] Other El <br /> Number of living units: --- ---- Number of bedrooms ---;�7 Number of baths 14 'Lot size ----- ...1.2 ------------------- <br /> Water Supply: Public system El Community system El Private Depth to Water Table(gr- ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam C] Clay or Adobe F] Hardpan ❑ <br /> Previous Application Made. Yes L] No � New Construction: Yes A No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewers available within 200 feet.) <br /> Septic Tank: Distance from nearest weII6lVev_1A9,stance from found,,tio------Z 4?------MjteTiaI__,11t�_. ------- ------ <br /> No. of compartments------31'__-------------Si,,_4dV./0__X_.�----Liquid clep�h----�EX�-------Capacify_)_;.-P 0 <br /> K t - -------------- <br /> Disposal Field: Distance from nearest well-&U414-Misfance from foundat' n ___-.__.Distance to nearest lot <br /> Number of lines------I-—------------ -Length of each line.... -------Width of trench__ .;L--- -_ , <br /> x Z ---- 4i-------------14------ <br /> Type of filter materiaJ_��T6�__ ____Depfh of filter material-----/-- ------------Total length-----/,&_0------------------------ <br /> Seepage Pit: Distance to nearest well------ ---------------Distance from foundation___________________ Distance to nearest lot line----------------- <br /> F Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Dept k--------------------------------V;, <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--- ------ ---------Lining material__.___---__.--___.____.___________-. <br /> El Size: Diameter--------------------------- ------ ---Dept h----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_._______.__._______.__._______._.____._. <br /> ❑ <br /> uilding--------------------- -------------------- <br /> ElDistance to nearest lot kne--------7------------------------------------------------------------------------------------------------------ ----------------------- <br /> Remodeling and/or repairing {describe)--------------------------------------- -------------------------------------------------------------------------------------------_------------------- <br /> -------------------------------------------------------------------------------------------------------­­---------------------------------------------------------------------------------------•---------------------- - <br /> •----=------•------- <br /> -----------------------------------­ <br /> ---------------------­­­---------------------------------- -----------------------------------------------------------------------_­-------------------------------------------------------------------------- ---.------ <br /> ------------------------------------ Z--------------------------------------------*----------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I ,F 0, prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, ander es.and regulations of the San Joaquin Local Health District. <br /> -71-z 1 PIA'4w j .1100 <br /> (Signed'i- ----------------------------------------------­­-----------r------------------------------------------------------------------ -----(Owner and/or Contractor) <br /> -- --------- -- <br /> By:--------------I ----------------------------------- -----------------------------------------(Title]- -------------------------------------(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be plaFced an reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY---- --•-------------- --------------------- ---------------------------------------------------- DATE----------------------- - - - ------------ <br /> REVIEWEDBY--- ------------------------------------------------------------ --- ---- - --------- --------- --------------•------- DATE-------- t_-, <br /> BUILDING PERMIT ISSUED--------------------------------------- ---­---­----------- DATE---- <br /> ------- <br /> ---------------------------------- <br /> Alterationsand/or recommendaf ions:---.---------- --- - - ------------------------------------------------------------------------------------------ -------------•----------•------------------------ ---------------------------------------------------------------------------------------------------­........ ----------I---------------------------------------------­----------------------- <br /> ----------------------------------------------------------------------------- ----------- ----------------------------------------------------------------I •-------•----------------. <br /> ------------ ----------------------- ....I---------------------- ------ -----------­­--------------------------------------------------------------------------- --------------------- <br /> ---------------------------------------------------------- -----------------------­­-------­­--------------------------------------------- -- ------------------ <br /> FINAL INSPECTION BY:-------------------- -------- ---------- - ----------------- ate----------- <br /> D - ------------------------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Sfockfon, California Lodi, California Manteca, California Tracy, California <br /> F5-9 14S446 A7WD=D <br />