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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <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 with County Ordinance No. 549. <br /> JOB ADDRESS AND OCAT,IIO�N------- ------ .._.. � = � � 'F ----------------------------------------------------1----------------- <br /> . me--- � PhonNaOwner's _ - <br /> Address-- 1-------------------- � --------------------------------- ---------- <br /> d • <br /> V <br /> Contractor's Name_------------------ -------- - ... Phone <br /> Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __/_-_- <br /> _ .__ _ umber of bedrooms -.e* Number of baths ._/--- Lot size _____________________ <br /> Water Supply: Public system/ Community system ❑ Private ❑ Depth to Water TabIQ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes ] ' No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ' <br /> i <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> t <br /> Septic Tank: Distance from nearest we1L_ <t '"Distanc, from foundation--- Materi <br /> No. of compartments_._ -.--__------_--Size � + _ _.Liquid depth_s- _.___Capacity___._ 1�___. <br /> D si posal Field: Distance from neardst well„ '1_-C-".Distance from foundation---,�r/__?_ ._.__.Distance to nearest lot line____5'._f_______- <br /> Number of lines-------I-------_......__/� Length of each line-----�� ._______ Width of trench----4__ .___________________ <br /> Type of filter material .._.___Depth of filter material------ ------Total length----- ` __________________________ <br /> Seepage Pit: Distance to nearest well- r u _____Distance f. m fo ndafion--,�0-_-_____-Daistance to nearest lot line___�r__r__._�____._ <br /> Number of its.-_ <br /> ..Lining material_- . _ _.__-$ize: Diameter__________ ._ ___Depth-----7 ___________________ <br /> Cesspool: Distance from nearest welL________________Distance from foundation.--------- ----___..Lining material------------_..____.____.__.__.______- <br /> Size: Diameter----- ----------------------______.Dept T --- _._-_ _Li uid Capacity a. <br /> - Iv <br /> Privy: 'Distance from nearest well----_--------------------------------------------Distance from nearest building---------------------------------- <br /> ❑ Distance to nearest lot line---------------------------------- --------------------------------------------------------------------------------------- <br /> �► <br /> Remodeling and/or repairing (describe)- ::���--��.r'�_��''.__v�:�_�'__ _ _ _ <br /> --------------------•--------. ------------------------•---•----------------------- -------------------- - -•-----------------------------------•--•---------------------------------------------------------------------- <br /> -----------------------------------------•----------_.-------------------------------------------Z••-------------------------.-.-_------.-..--•------------•-----•--------------•-------•-----------------------•------- <br /> --------------------------- -----------------•----------------------------------------------•--------------------------------------------------------- --- --- ------- .-- -- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)-------T- -----­------------------ ---------------------- -- ------------------ --------- ----- -- <br /> (Owner and/or Contractor) <br /> 4 Title <br /> By:-------•---------------���< �:w4-------- --•----------------------------------------------- ( } �_"' <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be place on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY...----- -- -- ------------------------------------------- DATE j� .�►- <br /> REVIEWED BY--------------------------------------------- ------- ------- ----- ------------------------- DATE-- - --y------------------------- <br /> -- <br /> BUILDINGPERMIT ISSUED--------------------------- ----------------------------------------------------------------- DATE.--- ---------------- <br /> Alterationsand/or recommendations:------ --- ---_----------------_------------ -------------------------------------------------------- ------ ------•-- -------------­­ - <br /> --- -•-----------------------•---------------------------------------- ---------------- ----- <br /> -----•----------------------------------------------------•---------------- --------------------------------------------------------------------- -------------------------------------------------------•-- -••------- <br /> ------------ -------------------------------------------- --/--`------- ---- - ............. ---------------------------------------------•--------------­­-------------------------------------------------------------------- <br /> FINAL INSPECTION BY:----- <br /> k C — .- ______________________________________ Date------------------- _�... 7= <br /> -- ----.__-._- <br /> ......�....... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American $tree+ 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> EF-9-2M 145446 ATWOOD� 12-5n <br />