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APPLICATION FOR SANITATION PERMIT Permit No- ----- 5 <br /> in Duplicate) <br /> • <br /> (Complete P � 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 Ordinances �o. 549. <br /> JOBADDRESS A L ATIOON------ ----------------15,, --•--------------------------------------------------------------------------.-----------------•------- <br /> Owner's Name----- -------f �f�' ---- -------------------------------------------------------------------- ------ ------- Phone------------------------------------ <br /> - - <br /> %Address-------------- s------ -------------------•------------------------------------ <br /> Contractor's Name------------- '" ------------------------------------------- ------ Phone------------------------------------ <br /> Installation will serve: Residence ®'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ <br /> f � <br /> Number of living units: _ -- Number of bedrooms _A—_ Number of baths _./__ Lot size --� --_______________________________ <br /> 10 <br /> Wafer Supply: Public system Community system ❑ Private ❑ Depth to Water Table 4_ f. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay ❑ Adobe lardpan ❑ <br /> Previous Application Made: Yes ❑ No gg­- New Construction: Yes ❑ No FHA/VA: Yes ❑ No <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 /> ❑ No. of compartments---------- - -------------Size----_---------------------=---Liquid del.t --------------------------Capacity---------------------- <br /> Disposal Field: Distance from nearest well-Op---------Distance from foundation____/990------_.Distance to nearest lot lin ____�~____.- <br /> [ � Number of lines__________ -_ /S <br /> ,t�-___-� Length of each �_____.Width of trench___line__-_- __�______fZ. _____________________ <br /> Type of filter material-A� __ __ .__Depth of filter material____ __________.Total length_--_�0---r---------- <br /> Seepage Pit: Distance to nearest well----XJJA0--------Distancefromfo��anon--.-/440-______.Distance to nearest lot line--- ______ <br /> Number of pits----/--------------Lining materia l_ 1' !_Size: Diameter__ `�_____.__.Depth-----AP__or <br /> ______-_------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------.____.Lining material_____________________________________ <br /> Size. Diameter--------------------------------------De th--------------------- -------------- ------------Liquid Capacity gals. <br /> Privy: Distance from nearest well-----------------------------------.-------------Distance from nearest building------------------------._-___-_______... <br /> ❑ Distance to nearest lot line------------------------------ ------------------------------------------------------------------------------------ --- <br /> Remodeling <br /> -Remodeling and/or repairing (describe):---------- l------ ---- ---`-- - - <br /> -------------------------------------------•------= --•-------------------------------------------•--------------------•----------------=-•-----------------------•-------•------------------------------•- <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 r es and reguf tions of the San Joaquin Local Health District. <br /> _______.{Si ned---------------------- Contractor) <br /> �j► may,. <br /> BY:----------------------------------------- t om' -----..,�----------------------------------------{Title}-�'F e �I <br /> (Plot plan, showing size of lot, lo-0ion of system in relation to wells, buildings, etc., -can be placed on revers side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATfON ACCEPTED BY------------- ---------- ------------------------------------------ DATE--------------- - <br /> --------------- -------- <br /> REVIEWEDBY------------------------------------------ �-4 -- -----------------------------------------------------------------. DATE -r <br /> BUILDING PERMIT ISSUED------------- - ---- =----- - - ---•--------------------------------------- DATE-�------------------------------------------------------ <br /> Alterations and/or recommendations:- I =----------------------------------- ----------------------------------------------- <br /> ------------------••----------- ----------------------------------------------------------------- ---------------------------------------•----- <br /> = ... - <br /> ----d <br /> --------------------------- ---------- ----------------------------------------- -------------------- <br /> -----•-----------•-•-- <br /> =�r-==5_ <br /> ---------- ----------------------------------------------------------- ------------ -------------------------------------------- ----- - ---------- --------------------------- ----- -- ----------•------------- <br /> r- <br /> FINAL INSPECTION BY:,. = _111 -------------------------- 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-9-2M . Revisep 1.57 F.P.Co. <br />