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APPLICATION FOR SANITATION PERMIT Permit No. ------------------­- <br /> (Complete <br /> s(Complete in Duplicate) 7 <br /> Date Issued <br /> Applic&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 LA"is made in compliance wit County Ordinance No. 549. <br /> LOCATION_______.__,_ <br /> - ----------- -------- ---• - ---------------------------- <br /> JOB ADDRESS AN <br /> Owner's Name-------- ............T ---- --•--•---•------------------- - -------- ------- Phone-- - ------- <br /> 0. <br /> Address ----R-6=---- ------- --- ---- --•• ----------4��5 <br /> Contractor'sName ------------------' j�1, ur1lF4,r� ---- ••---------------------- Phone----------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercials Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ________ Number of bedrooms -------- Number of baths ________ Lot size <br /> Water Supply: Public system ❑ Community system ❑ Private ©✓Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoamjR' Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ I <br /> Previous Application Made: Yes ❑ No;g_ New Construction: Yes ❑� No_'g <br /> TYPE OFINSTALLATION.AND..SPECIFICATIONS: ` <br /> / <br /> {No,,reptic-tank or cesspool permitted if public sewer is available within 200 feet—.l r <br /> Septic Tank: Distance from nearest well_t> ___Distance from foundation---!U____-_- <br /> No. of compartments---------- --- --Size-_- _1_7-x_J___Liquid depth--------- -------Capacity------- U__ -- <br /> Disposal Field: Distance from nearest well-_--- ---------Distance from foundation--------------------Distance to nearest lot line___-________-_--- <br /> r ❑ Number of lines------- -------------------------Length of each line-------_----------_--- -Width of trench-------_-------------------------_ <br /> �i Type of filter material-------------------------Depth of filter material----------------------._Total length--------------------------- <br /> _______________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation__________--_._.___ Distance to nearest lot line-----__________-_ <br /> ❑ Number of pits----------------------Lining material--------------------_--Size: D':ameter-----------------,-----Depth---------- --- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation----------Y____-_- Lining 4materia -- <br /> ❑ Size: Diameter--------------------- ------ -------Depth--------------------- -----------------------------Liquid Capacity----------------n----------gals.4— <br /> L <br /> ____________________________Distance from nearest building________.______-_ <br /> Privy: Distance from nearest well.-.-.__________-._. -------------------- � <br /> ❑ Distance to nearest lot line----------------------------------------------------------------•--, I <br /> i <br /> Remodeling and/or repairing (describe):--------- ------------------------------------------•----------•-•------------j <br /> s <br /> •-•------------------•-•-----•--------------------------------------- ---------------•------••--------------•••---------------------------------------------- ------------------------ -------------------- <br /> Tj <br /> 1 � <br /> ---------------------------•----------------•----- -------- -------------••-----------------.--.......----------------------------------------------------------------------------------------------------- ----------------- ' <br /> I hereby certif hat I have prepared this pplication and that a work wil be done in accordance with San Joaquin County <br /> ordinanceXtfafw , and les and regul i sof the San Joa i LocalHh Dis ict.s _ r---- w= - '4------------------------------ <br /> (Signed) --------(Owner tar) <br />. - <br /> By: __9----- - 4--------------------------------------------- -(TitI )Q__ 0- <br /> - -----------* <br /> ` (Plot plan, showi g zeiof lot, location of system in relation to wells, buildings, etc.;can be-pla d on. reverse side].=__-. — — <br /> F R Fj4T SE ONLY <br /> APPLICATION ACCEPTED BY ---------- DATE----r�`_.:f 5-- ---77;1- -----•-------------- <br /> REVIEWEDBY------------------------- ------ ------------------------------------------•---------------------------------- ----- DATE <br /> BUILDING PERMIT ISSUED-------------------------------------------------------------------------------------------- --------- DATE----------------------- <br /> Alterations and/or recommendations------ - -----------------------------------------------•-•--------------------•---------------- <br /> ---------- •------------•-•-------------- -----------------------------------------------------------------------------------------•-----•---------•---------------------------•----------- <br /> •--------------------------------•----------------------------------------------------------------------- ------- -----------------•-----•--------------•---------------------•------------------------------------- <br /> FINAL INSPECTION BY:.------#//e <br /> Date l.- l. a_. <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 /> -9-2M 145446 ATWOOD 12-54 <br />