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�,'.: sa '..,'... ... -r�--- •a*_ tee `. _ _ :.re. <br /> Mc <br /> � i <br /> APPLICATION FOR SANITATION PERMIT Permit No. .. <br /> (Complete in Duplicate) Y' <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 jwy h Co my Ordinance No. 549. <br /> JOB ADDRESS AND LOCA O .y L�!. r. <br /> --- ---------- ..................- <br /> � cc <br /> Owner's Name............. W- ----- •------ - - -- ...... ----- -- ... .............. one .. <br /> .---..._.... ---- --------- <br /> Address.........I,+ <br /> . -� -- <br /> -../-...... -- . -•--.----- <br /> Contractor's Name........ -------------.....................................................................--------------------------------------------- Phone....---•--•...................... <br /> Installation will serve: ResidentApartment House F1Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> �umberNumber of living units: .___ of bedrooms .._�_. Number of baths ._�..._ Lot size -_.:-_ ........................ <br /> Water Supply: Public system ❑ Community system 0 Private ❑ Depth to Water Table A-.rft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ClayX Adobe Q Hardpan ❑ <br /> Previous Application Made: Yes ❑ No` I ' New Construction: Yes V 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: Distance from nearest wellid. - __ istance from foundation-----16.........Mat ial-_ ,,Q"'1.'Ch .......... <br /> No. of compartments_.._--[ -______- -_.Size._s�..�x_n _ Cz:_._.Liquid depth---- �-------------Capacity. . .............. <br /> Dispo al Field: Distance from nearest well - Distance from foundation..............Distance to nearest list line._b----_.... <br /> Number of lines---------------f .. .__------- Length of each line.........�__Q.___l ....Width of trench ,�� _._ <br /> Type of filter materia-------- � pepth of filter material-------�.�_u. Total length-----.Zy.'........................ <br /> Seepage Pit: Distance to nearest well______________________Distance from foundation....................Distance to nearest lot line._--.-.-__--_--- <br /> ❑ Number of pits______________________Lining material-----------------------Size: Diameter-----------------------Depth--.-._-____-___-__.....___....... <br /> Cesspool: Distance from nearest well-----------------Distance from foundation...-----------------Lining material----------------_._-__-_..._____----. <br /> 171Size: Diameter---- -- --------- ----- --------Depth---------------z-- ----- ------ ----Liquid Capacity --------- ------ <br /> Privy: Distance from nearest well_-------------------------------------- --- ---Distance from nearest building------------------------------------------- <br /> Distance <br /> -.__. -_-.__-__ -__ ______-.Distance to nearest lot line-------- -------------- ---------------- ---------------------------------------------- -----=- -- <br /> Remodeling and/or repairing (describe):-------------------------- ----------------------------------------•----••------------------------------------------------------------------------------- <br /> .........................-------------------------•----------------------•--------••----------------------------------------------------------•--•---------------------------------•---------•----------------------•-•----- <br /> -----------------•--------•-•-•---•--••---•-----------•-----••------...------------------•--------•---•---•-•------..........-•---...-•---------....---------•-----•---•-••-•--•----•------...--•-----••--------.........__.. <br /> •--•----•------•----------•--•---•------•------------------•----------•------------------•------•----•---•---•-----....------------•---...----•-----------••-----•--------••----------.-...----•--•-----------•----•--.----- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wifliSan Joaquin Counfy <br /> ordinances, State laws, and rules end regulations of the San Joa uin local Health District. <br /> (Signed).... _-- _- ---------------------------------------(Owner and/or Contractor) <br /> ..� <br /> -- -•---------•------•----- --•-----------------------•-----------------------------(Title)-------------------------•--- ------ <br /> (Plot plan, showing size of Jot, location f system in relation to wells, buildings,etc., can be placed on reverse side): <br /> FOR DEPARTMENT USE ONLY `J <br /> APPLICATION ACCEPTED BY--------- --------------- ------------------------------------- ---- ------••-----•---------- DATE.....................•---- <br /> REVIEWED BY--------------------------------------------------------------- DATE.....*. . „' <br /> ------------ <br /> BUILDING PERMIT ISSUED------- •----------- - . . . ................... DATE--------•----------------------------•------- <br /> Alterations and/or recommendations------=--------------- -------- ---------------------•-••---•------------------------•--------------•---------------•-----•------•----------- <br /> ............................. -•---------.....--------------------------------------------------------------..........:-.............................................................................................. <br /> ------------------------------------------------------------ <br /> / ..� <br /> FINAL INSPECTION BY:. .. ------ .. Date- l-. <br /> 7............... ­.. ............ <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 145446 ATWOOD 12-54 <br />