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APPLICATION FOR SANITATION PERMIT Permit No- ----- Z <br /> (Complete in Duplicate) <br /> Date issued ------------ -------•- <br /> Applica4-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 LOCATION__-'�_� _.--.__ sr._-.-' .fir___________________________ <br /> _ �j� <br /> Owner's Name-----�----�==--------,T--- lze� _/ ------------ . Phone-------------- --------------------- <br /> Address.... <br /> -------Address.... E------------•-----------------------------..----•------------------------- <br /> Contractor's Name-------Ai -/ -- -------------- Phone--------_------------------------ <br /> Installation will serve: Residence [J partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___/_- Number of bedrooms ---_umber of baths ._-_/-- Lot size .._�. _ __.__ f------------------------ <br /> Water Supply: Public system ❑ Community system ❑ Private Ug--E1e-ofh to Water Table -------- ft. n <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[4-Hardpan ❑ <br /> Previous Application Made: Yes ❑ No.-�New Construction: Yes ❑ No E '' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 4. <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic,T.�''k: Distance from nearest well----- -----------Distcince from foundation-__-_-_-___-_--__.Material--__-__..-__--_--.--_,__.__---------_---._-_--. <br /> DJtrt r41Xr No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity..-------------------•- <br /> Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line--__--__----___-- <br /> ❑ Number of lines--------------------------------__Length of each line-----------.-----------------.Width of trench--------------------------------__ <br /> Type of filter material-------------------------Depth of filter material------.---------------.Total length----------------------------------_-.---_. <br /> Seepage it: Distance to nearest well.._/_Q__d......Distance from foundation___-- ----_.Dis ance to nearest lot iine__L0___ _ <br /> Ili <br /> - - , <br /> ' ---- Depth_...Number of pits - - -_Lining materialSize: Diameter.--_ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------:......Lining material-_..--__-_______-_.--_______-.-__-_. <br /> ❑ Size: Diameter---- - ------------------- ----------Depth------------------------------------------------....Liquid Capacity------------•-----------....gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____-____--.._.--___------..._-_-__-.-. <br /> ❑ Distance to nearest lot line----- >-----`- ------------------------•----------........_.----------------,---------------------------- ------- <br /> �' < , J` 116W.4 L /_t Al-Remodeling ✓' <br /> and/or repairing (describe) - ------------------------------------------------�1��- -- ----- ------ -I------------------------- <br /> •-•--------- -------------------------•------- -------------• .-------------------------------------•----------•------------------------ <br /> A <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 and rules and regulations of the San Joaquin Local Health District. <br /> .r' <br /> Are G_j_ er and or Contractor <br /> (Signed)........... ..... --�----!4--------- - ------------- ------- ------ - ( / ) <br /> B ----- ---•--- ------(Title)--- ------ <br /> (Plot plan, showing size of lot, ocation of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- -----_------------ ---- -- ------ ------ ---------------------------------------- DATE-----------, ------------------------------------------- <br /> !to, <br /> ----------- - <br /> -- -------------------------- <br /> REVIEWEDBY--------------------------------- ------- --------------- ----- ---------------- -------------- -------------------------- DATE------------------------^-------------------------------- <br /> BUILDINGPERMIT ISSUED------------------- ---------- == --- --------------•-••------------------------ -----------... DATE------ ---------------- ---I ------------------------------ <br /> Alterations and/or recommendations:----- ---- -•-- ----- ------------ ----------------------------•------•----•--•------••---•------• --------•- -- -- f <br /> -------------- - --- - --- - - I ---- ------ --- ----=-----------------------___----------------------------------------------------------------------------- -------•------•-•---------- <br /> FINAL .INSPECTION BY:... @A.[ ---------------------------- -------------- Date..... `. c�� <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 /> En­9 145446 ATWOOD <br />