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APPLICATION FOR SANITATION PERMIT Permit No. ..Ak <br /> (Complete in Duplicate) Date Issued 4- <br /> ,pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hereirl-clitscribed. <br /> -mis application is made in complian ith County Ordinance No. 549. <br /> 0!!201 U/Ir, <br /> ':)B /.oDRESS AN OCATI 14 .....-. ......... <br /> . ..... .... <br /> .... ..................... <br /> . . .......... 4 <br /> 6 .........I ... .. <br /> 1w .......-................� P 0............................... <br /> ner's Name. . .............. . t <br /> AddresL............. . ... .... )_ A _... ------------------- <br /> . ............. .......................................... •.......................... <br /> ontractor's Name._. . ......... .............................. .. .... ............................................... Phone.................. <br /> ..wt&Paf;on will serve: Residence Apartment House [] Commercial 0 Trailer Court 0 Motel 0 Other <br /> Number of living units: Number of bedrooms ........ Number of baths ....... Lot size --❑ <br /> ----- <br /> later Supply: Public system 0 Community system [3 Private (k Depth to Water Table i�'ft'-­' <br /> Character of sog to a depth of 3 feet: Sand I-] Gravel x Sandy Loam E] Clay Loam C] ,Clay Adobe 0 Hardpan 0 <br /> "wicus Appkafion Made. Yes (:] No V New Construction: Yes x No C] <br /> YPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted of public wer is Jvailable within 200 feet.) <br /> pu ic <br /> epfic.T istance from nearest well 3 rt..&,�ce-from foundation.................. Material. ...... ... . . .............................. <br /> ic'T <br /> No. of compartments............ ...... ....Size............-..................Liquid depth.......... .. ....... Capacity....................... <br /> IS al Field: Distance from nearest wela.....TS'stance from foundation....110-.....Distance to nearest lot lirie.;nae <br /> i t o trench. ..... ­;.�., ......7 <br /> Type of filter material..... Depth of filter material �Zo <br /> Number of lines.... .......... .-Length of each line..... d Is f rich <br /> 9 al length........ ................... <br /> -jeepage Pit: Distance to nearest well.....................Distance from foundation.._........._......Distance to nearest lot line-..............7010 <br /> E] Number of pits......................Lining material......................Size: Diameter.._......._ .._....Depth. ... ...... ..................1. <br /> :esspool.- Distance from nearest well.................Distance from foundaticn Lining material.. .............. ............*....I <br /> 0 S:iv: Diameter. ...._...... ... . . ......Depth............ ........... . Liquid Capacity. ............. .........gals.� <br /> Privy: Distance from nearest well. . ..... ............................ .. Distance from nearest building.. ......... ....... <br /> ClDistance to nearest lot fine. ................................ ................................ .............. ............... . -....... <br /> d or rep 'ring <br /> scribe):, <br /> lemodeling an <br /> ......... .......................... .......... . . . . .11-t-4............... ...............I..... ... <br /> r .... .... ....................... ........ ...... <br /> ........ .......... ..... ................................................................................................................... <br /> ---------- prepared...... .........*....................**"*---------------*--------------*....... . ... ................. ..... . <br /> I hereby certify that I have ppared this application and that the work will be done in accordance with So-n Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> .... ........ (Owner 4 nd/or Contractor) <br /> .................... . ... ......... .. . ................ (Title). . . . ......... <br /> Plot plan, showing sin of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> NPPLICATION ACCEPTED BY DATE r <br /> ZEVIEWED ByDATE.L7_ _ <br /> ..... <br /> IIJILDING PERMIT ISSUED. DATE_ <br /> Alterations and/or recommendations:. ..... ....... . ........ <br /> Ci.'AL <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 110 South Arr*,,Cer, S11,000 300 Woo Ook Sf,eef :32 Sycamore Street 814 N-11% St,*.# <br /> st,cloo.. Cei In,-& Lod; CA1;fo,r,:a mo.t*ce. C61,10r,4 T-*cY, <br />