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-3- <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> ... ....... <br /> (Complete in Duplicate) Date Issued <br /> Application 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 /> a I e - <br /> JOB ADDRESS Al LOC TION......1_73 4_.�- -------------------------------------------- ---------------------- <br /> P 6--------------- <br /> P one+___]19_1---------- <br /> Owner's Name..---- <br /> -------------- - ------------------------- <br /> ----------- <br /> Address--------­------- ..... .. ......... -- -------------- --------------------I-------------------------------------------------------------- ----------------------------------- <br /> Contractor's Name---- ----------- ------------------------------------------------------------------------------------- gone- ---------- <br /> Installation will serve: Residence\&4 Apartment House ❑ Commercial E] Traile Court [:1 Motel El Other El <br /> Number of living units: Number of bedrooms Number of baths ___ 'yLot size _1 <br /> ----------- <br /> Water Supply: Public system 1Z, Community system E] Private 171 Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 fee+: Sand E] Gravel E] Sandy Loam E] Clay Loam Ej . Clay E] Adobe;K Hardpan E] <br /> Previous Application Made: Yes E] No� New Construction: Yes1S,'_No El <br /> f . <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 well_________________Distance from foundation--------------------Material-------------------------------------------------- <br /> El No. of compartments------ -------------------Size------------------------------Liquid depth---------------- --------capacity----------------------- <br /> Disposal Field: Distance from nearest we€l_-----------._Distance from foundation-------------_-----Distance to nearest lot line.._...__...._._.. <br /> C1 Number of lines-----------------------------------Length of each line--------_---------------------.Width of trench-_----------------.----_---------._ <br /> Type <br /> rench----------------------------------- <br /> Type of filter material-__ Depth of filter material-----------------------Total length______________.________________________-._ �► <br /> Q <br /> Seepage <br /> ength------------------------------------------ <br /> Seepage Pit: Distance to nearest we1I_.)Ah_t_____Dis e, from/foLkndation J.0- Distre nearest I° line-----4--------- <br /> \R�f - --- e-t' -­ N Depth <br /> Number of --------------Lining ma Size: Diam erq-", <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____.______________.____.____________. <br /> ❑ Size: Diameter-----i---------------------------------Depf k--------------:---------------------- --------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well--- -----------------------------------------------Distance from nearest building__________.__._____-----__-______-_____. <br /> ❑ Distance <br /> uilding------------------------_-------------- <br /> Distanceto nearest lot line-__-_ ------------------ ---------------------------------------------------------------------------------------------------------------- to <br /> Remodeling nd/yr re --- -­T-j6 ------ <br /> -------- <br /> - ------- <br /> ----- - -- ......... --------------- <br /> ------------ --------------------- ------------------- ------------------------------- <br /> ------------- ---------- --------------------------------------------------------------------------------------- <br /> ---------------------------------------I-------------I--------------------------------------------I-------------------------------------------------------------------------------------------------- ---------­--------------- <br /> I hereby certify that I have prepared this application and that the 'work will be done in accordance with San Joaquin County <br /> ordinanc State laws, and rules and regulations of the San Joaquin Local Health District. <br /> kL-.,.,----------------------------------------------------------------------------------(Owner and/or Contractor) <br /> By:----------------- --------------------------------------------------------------------------------------------------------------------(Title)---------------------I.,---------------------------------------- <br /> (Plot plan. showing-size of lot, location of system in relation to wells, buildings,-etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY-------- *----------- --- ----- --------------- -- ---------------------------------------- DAT ---------------------------------------------- <br /> REVIEWED BY------------------------------------- - <br /> -- -- ---- --- ---- ------------------------------------------------------------------- DATE------------------------ <br /> BUILDING PERMIT ISSUED.- - ---------------- --- ---- -- DATE <br /> ---------------- ------------------------------ ---- <br /> --- <br /> ------------------------ <br /> Alterations and/or recommendations:------------- -------------- - ­ --­----------------- __­_-�---_-- ------------- <br /> ------------------------------- ------------- ---------------------------I--------------------------­­-------------------------------------------------------------------------------- ---------1-N-------------- <br /> --------------------- ------------------------------------------ -------- -------------------------------------------------------------- ----------------------------------------------------------------- ------------- <br /> ---------------------------------------------- -------------------------------------------------------- ------------------------------------------------------------ ----------------------------------------------- <br /> -------------------------------------- ------------------------------------ ------ ------------------- --••----------•-- --------------- -----------7----------------------------------------------------------------- <br /> FINAL INSPECTION BY:------i5_21j.__S; ---------------------------------- <br /> -------------------- Date. ---- <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-0-2M 145446 ATWCUP 12-54 <br />