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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <br /> __`���/.SZ- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install"work h ei'm described. <br /> This application is made in compliance with County,Ordinance No 9. <br /> JOB ADDRESS AND LOC�AWT14,,_� <br /> -------- -- ----- -------- - ------ <br /> may,--- -------- --- -- - - ---- ------ - <br /> Owner's Name---- - -----+--- 0 - <br /> ------- -------- ----- ----- - -- ----- -------------------------------------------- <br /> Phone <br /> Address------------------ <br /> ----------------------- - -------------------------------------------- <br /> Contractor's Name--------- -------- -- -------- --- -------------------------------------------------------------------------------------------------- Phone <br /> Installation will serve. Resi ence Ej Apartment House [:] Commercials Trailer Court [] Motel El Other 0 <br /> Number of living units: -41�71\lumber of bedrooms dg Number of baths G Lot size <br /> Water Supply: Public system E] Community system E] Priva 1e� Deptk to Wafer Table -------- ff. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel Ej. -Sandy Loam El Clay Loam E] Clay <br /> Adobe Hardpan E] <br /> Previous Application Made: Yes 0 NO NCS No E] 4, <br /> F] <br /> 'Ar ew onsfruction: Ye> <br /> TYPE OF INSTALLATION AND SPECIFIC TIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank. Distance from nearest well--;: If, ion -- Material <br /> ----Distance from founclaf <br /> - --- <br /> ----- <br /> No. of compartments-__-__-- ----------Size------ ------------Liquid depth---- <br /> Capacity----- <br /> Disposal Field: Distance from nearest well------------------D'stance from foundation--------------------Distance to nearest lot line___________----- <br /> F1 Number of lines-----------------------------------Length of each line-----------------------------.Width of trench <br /> Type of filter material__________________ Depth of filter material______-----------------Total length___-________________________________----- <br /> Seepage Pit: Distance to nearest well----AlDistance fTm fou dation- <br /> Depth <br /> to nearest lot line----- --------/ <br /> Size: Diameter______ --- ------------- <br /> Number of pits_________------".--Lining material- -------------Depth----/ <br /> Cesspool: Distance from nearest well--------- ------Distance from foundation______----_.______Lining Lining material-------------------------------- <br /> El Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest Weill---- c-,!- <br /> - -----------------------------------Distan e from nearest building---- ---- <br /> F1 Distance to nearest lot line------ _ <br /> ❑ <br /> ----- --- �------- <br /> Rem elincl and r repairing descAe)---------- - --------- <br /> ------ ---------------- ------------------------- -- -- ------------------------------------ ------- <br /> e--------------- <br /> ----------- ----------- --- <br /> - -- -------- -- ---- ------ <br /> _P�------------------------ <br /> ---------- <br /> ------------ --------- -- ----- --- - -------- ----------------- .--- ••----------------------•----------------------------------------------------- -------------- <br /> r c ify t at I,-' prepare r application and that the work will be done in accordance with San Joe in County <br /> o innces. State la ndrules n regulations of the San Joaquin Local Health District. <br /> (Signed} ----------- ------- ------- <br /> ------------------------------------------------ (Owner and/or Contractor) <br /> By:-------------- ---- ­- ----- ------------ -- ----1, -A-- ----- ------ -------------------------------__(Title]--- <br /> (Plot plan, showi4g. - e of 04. ocatif�o #em in relation to . S, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- -------------------------------------------------------------------------------------------- DATE� <br /> REVIEWED BY -------------------------------------------------- <br /> -- ----- ----- -- ---------------------- ----------------------------------- DATE- <br /> BUILDING PERMIT ISSUED--------------- ----------------------------------------------- <br /> --------I----------------------------------------------------------------- DATE----------V* <br /> �e------------------------------------------- <br /> Alterations and/or recommendations:---------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------I------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -----------I-----------------------I----------------------------------------------------------------------------------------- <br /> ------------------------------------- ----------------------------------------------------- ------------- - --------------------------------------- <br /> ------------- ----------------------------------------------------- <br /> - <br /> - <br /> - <br /> - <br /> FINAL INSPECTION Date--------._ 1-6 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Streef 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 8-51 Rev'ised W-2100 <br />