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1N Z: <br /> Ar7CATION FOR SANITATION PERK( Permit No. <br /> +� (Complete in Duplicate) <br /> Date Issued ._� _ -_----`_ <br /> Applica+ion is herebyimade 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. <br /> JOB ADDRESS AND'.LOCATION_________ <br /> ----------------------------------------- --------------------------------------------- <br /> Owner's Name__ -_�� .-•-- -- --------••-----•----•-•---•-•-----•• ------ <br /> i <br /> J -- ------ Phone. <br /> ---------------------------- <br /> Address <br /> --•-Address-------------- ------ ---- _ <br /> ------------------------------- <br /> Contractor's Name-~ «r --2- Phone <br /> Installation will serve:� Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _ ----- Number of bedrooms ----2--Number of baths /--_-_ Lot size ----- __--:- <br /> Water Supply: Pubic system E] Community system El Private N_ Depth to Water Table _�C>ft. <br /> Character of soil to eldepth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe)Hardpan ❑ <br /> is i <br /> Previous Application Made: Yes ❑ No 3,New.Construction: Yes 2� No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS•: . <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank- <br /> --Distance from nearest weil-----------------Distance from foundation___ _ _ <br /> ------.---_ _-..Material__..--.._.-_---._-_-_ _._.___.._______.__-_____. <br /> [] � 'of compartments-- -----------------------Size--------------------------------Liquid deptly------------------------.Capacity <br /> p ce from nearest well............. <br /> .......... ....Distance from foundation..........._.._....Distance to nearest lot line................. <br /> ❑ l um of lines--------- -- ----------------------Length of each line--------------------------- :.Width. of trench------------------- <br /> Type <br /> Dis osa Field:. Di <br /> T pe of filter material______------------- <br /> -----Depth of filter maferial__.------.------------Total length--_----_-____-_--------______---_ <br /> y <br /> Seepage Pit: Distance fopnearest weli_.`1_'�_--__-_Distance fro�mm.f dati��_.4—�?_..-_.Distance�o nearest lot line--_��d._` <br /> 4 ._. <br /> Dumber of its__._. -_.__----_-Linin material_ ¢e: Diameter-----� ____--Depth__._ ________ <br /> ----- <br /> Cesspool: Distance from nearest-well----------_------Distance from foundation--------------------Lining material---------------------- <br /> �e: Diameter--- - Depth ------------•------------ -----------Liquid Capacity-------••------------------gals. <br /> Privy: Distance from nearest w.ell------------------------------------------__-_.-Distance from nearest building.--__._,--.----_----__ <br /> ❑ Distance to nearest lot line--------------------------------------- ---------••-__--- <br /> Remodeling and/or repairing (describe):--------------- <br /> - -----------------------••-----------------------•----------------------.._. <br /> ------•--•-------------•--•----------... <br /> ----------•--------------------------------------------------.------------------------- <br /> ------------------ -------------------------- --------------------......--•------------------•---------------.---- =-- ••-----------•- <br /> hereby certify th ave prepared this application and that the work will be done in accordance with San Joaquin.County <br /> ordinances, State rules and regulations of the San Joaquin Local Health District. <br /> �s <br /> --- 1 <br /> ( igne�} ' ----------------(Owner and/or Contractor) <br /> -------------------------------- <br /> $Y� '1��� -� -- --------- ..... -- -- -- ----------------------(Title)-----G�' ------- <br /> ---------- -------------------------------------- <br /> ---------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> ;t <br /> It <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY \ --------------------------- --- DATE----- - - <br /> REVIEWEDBY -- -`------------------------------- -- ------------------------------------ DATE <br /> BUILDING PERMIT ISSUED------------------------------------- --------------•--------------------------------------- DATE..--------- ---- .. <br /> Alterations and/or recommendations---------------------------- -- -- - <br /> rl � <br /> ---------------------------- <br /> ---------- ----------------------------- . ---- - �—." <br /> ---­---------------------- <br /> --------------------------- ----------- - ---Ir ! <br /> -------------- L--- --•---------------------------------------------•-----------••----------------••------------------••--- <br /> Il <br /> - ------------------------------ <br /> FINAL INSPECTION BY:..-.,57----)- --------•-----••-•---------------- Date.... <br /> ------ ----------------------------------------------------- <br /> 1 <br /> r <br /> h 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 /> F5-4-2M t4S as nrwaoo ISI lz-sa <br />