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A <br /> 'APPLICATION FOR SANITATION PERMIT Permit No. _ ----------------- <br /> i (Complete in Duplicate) <br /> Date Issued <br />?iApplicallon is hereb made to the S6n Joa uin Local Health District for a ermit to constru t y q p c and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. �I <br /> JOB ADDRESS AND OCATION------- 0 �411� � �=--- ------ - -------------T <br /> ----------r------�------------------- <br /> f <br /> Owner's Name ---------------------:--- - - -- ---- . P h o n 4 �-:�"- <br /> Address----------------------------------- ------------- ---------------------------------------- <br /> Contractor's <br /> --------------------Contractor's Name------ -•----- ='� r ----------------------------------------------- ---------------- Phone�--C IV-6-0 <br /> Installation will serve: Residence 5�­Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Ll <br /> Number of living units: __._ Number of bedrooms _� Number of baths 1____ Lot size __ /-S?� -�� <br /> , r <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 Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2-- kardpan ❑ <br /> Previous Application Made: Yes ❑ No Lam" New Construction: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: • ► <br /> {No septic tank'or cesspool permitted if public sewer is-available within 200 feet.} <br /> '--pt�T :t DisNotof compartme tsance o-ni t well_°_DZeance from foundatiL qu' :__._.Material__G� ________ ______ ____________________s <br /> - th-----•---------------------Capacity---1--------•----------- <br /> o{a ald: Distance from nearest well-_-- ,Distance from foundation--------------- <br /> -.--.Distance to nearest lot line_______._______ <br /> ;Nu'mbbr of,lines-----------------------------------Length of each line------------------------------Width of french------------------------__.---_------ <br /> Type of filter material------------------------Depfh'of filter material--------------:__-----Total length-----.,-•----- JJ1I�I�-�-------- ------ <br /> See a e it: Distance to neare t welly _ Distance from oundation_ - _` _ ri <br /> p g �____= _____.:..Distance to nearest lot Ii ie_ <br /> Number of pits___r --------- - material_ _ Size: Diameter_"5_:s----- De th-. <br /> Cesspool: Distance <br /> eter_nearest,well__=---� ---:__Depthte from foundation-.-=_---.-_--= -,��quid Capacity_______'______---_________gal <br /> s. �1 <br /> , a 1 <br /> Privy: Distance from nearest well______________________{______-___-_,__,__--_--_Distance from nearest building---------s___I-------------------------- <br /> . I, <br /> ❑ Distance to nearest lot line_------ ---- k=------ } - -----------------------------I. <br /> -------------- <br /> Remodeling and/or repairing (describe): v --------------------------------------------------—-- - ; <br /> --------------------------------------------------- --------------------------------------------- _. <br /> ------------------- <br /> ---------------------------------------- --•----------------- -- -- <br /> 1L <br /> I hereby certify that ha a prepared this ap lication and-that t e work will be done in accordance with San.JoaLin County <br /> ordinances, State laws;:a r es and, re ulationi of the San Joa u' Local Health District. <br /> = - M <br /> (Signed)-------------•--=-•--•--• - -----------� ------I------ ----------- -------- -----=-=--------------- -----••-----------=-------• I Contractor) <br /> B <br /> Y= =--------=----------------�-'--- Title)- - -------------- <br /> {Plot plan, showing size of lot, location of system in rel ion t wells,' buildings, etc can be placed'on reverse side}. <br /> FOR DEPARTMENT USE ONLY II <br /> APPLICATION ACCEPTED BY--------------------- ---------=-------------------------------=------------------------- DATE------- ----------------- ------------I- <br /> ------------- <br /> REVIEWED BY------------------------ ----------- ,.------------ DATE--- - - <br /> BUILDING PERMIT ISSUED---------------------- -----------------------------------•-=---------------------------- DATE----- I <br /> Alterations and/or recommendations: ------------------------------------------------------------ ---- �- --------------- <br /> ------------------------------------------------------------------- -- <br /> ------------------------------------------------- ----- <br /> ____________________________________________________________ _ <br /> F1NAL INSPECTION _--==- �' Date = <br /> ------------------ <br /> BY: I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, CaliforAia <br /> II <br /> 3=S-4-2M Revised W-2100 <br />