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APPLICATION FOR SANITATION PERMIT Permit No. ----- <br /> (Complete in Duplicate) <br /> Date 1ssue4---53-.-- WA) <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 /> JOB ADDRESS ;AN LOCATION-- --------- -----► --- -- -------------------- ------ <br /> --------------- <br /> L --------- <br /> Owner's Name--- ------------ Phone---- -------- ---------- <br /> Address-- <br /> ----------- -- ------ ------------------------- -------------------------------------------------------------------------- <br /> Contractor's Name-- ------------ ------------------ -- ------------------------ - ---- -------------------------------------- Phone------------------------------- <br /> Installation will serve, Residence parfmorif House E] Commercial E] Trailer Court E] Motel L] Other E] <br /> Number of living units: _i!_.... Number of bedrooms Number of baths J---- Lot size ---�­(9-1--------I At ------ ----------------- <br /> Wafer Supply: Public system Ej Community system E] Private E] Depth to Water Table ------­ ff. <br /> Character of soil to a depth of 3 feet: Sand F] Gravel E] Sandy Loam El Clay Loam El Clay El Adobe Hardpan E] <br /> Previous Application Made: Yes E] No IX New Construction: Yes A No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septi Tank: Distance from nearest well... -Distaqqe)fpom foundlaf�iop <br /> .ij.0­ ----------------- - -------- <br /> No. of compartments `i'� ..... d <br /> ep. h­. Capacify--�?.e�-c-------- <br /> Disposa� Field: Distance from nearest well Distance from fou d fl)n--j-'�,-' ­Qisfance to nearest <br /> Number of linesA5-------- Lerig�h o� each h6-� <br /> i.:11109— ­­`.......OiX'of <br /> X: <br /> Type or filter material_�,,'/ of filter mate is____..._..7777T. -q-1!­TofaI length.___ ---- <br /> Seepage Pit: Distance to nearest well-- -- - --------------Distance from foundation___---..--_-_-_-.- Distance to nearest lot line_._......... <br /> El Number of pits------------------ --Lining material----------.-----------Size: Diameter---------- ------ ----Depth-----..-------- ---- ------------- <br /> Cesspool: Distance from nearest welt_____________ ---Distance from foundation . . ------------- Lining material__--______-__----_---__._._..__ <br /> ❑ <br /> aterial--... -------­---------------- <br /> Lj Size: Diameter--- ------ -- - ------ ---- -Depth----- ----- ------------------- ---- - - - r --Liquid Capacity------ - ---- - gal <br /> -------- <br /> Privy: Distance from near-est well._-_-.._.__._..__. ......................Distance from nearest building._..- - -- --- --------------- <br /> Distance to nearest lot line - -------------- <br /> Remodeling and/or repairing (describe): <br /> ------------------------------------ ------------- ---- ----------------------- ------------------ <br /> 17 <br /> -------------------------------- -------- - ------------------ <br /> -------------- --- - --- ----------- ----- --- ---- ----.. ­.- ­ <br /> ------------------------- <br /> I hereby certify that I ha4'prepared j",applicif be dc�ie in accordance ifh S n -&aunty <br /> ion and that the work will <br /> ii� rL <br /> ordinances, State la4s,,,�nd rules an ula+ions of the San Joaquin Local Health District. <br /> t <br /> (Signed)---------------------------------------- ------- <br /> -------------- ---- - -------------- - -- ---------------------- - - --- -----------------(Owner and/or Contracforl <br /> By:------------------------------------------------------------------- ------ ---------------- - --------------------- - ---- - -----(Title)-- <br /> ----(Title)--------- -------------------------------- - - ---------- <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 /> APPLICATION ACCEPTED BY----- ----- ----------------- `:DATE----- <br /> REVIEWED BY <br /> -------------------------- ---- ---- --------------------------------------- DATE-- <br /> BUILDING PERMIT ISSUED--------------- ­., <br /> -------------------- ------- --------- DATE........ <br /> Alferafions and/or rec mendations:.- <br /> --------- - -- --------------- ------- ----------�-., ............. ------------- <br /> ---------------; <br /> ----------------- ------------------------ ---------- ----------- - ---------- - -------------- -------------------- ---- -----­---------- --------------- --- ------------- ------------------- <br /> --------- -------------------­-­......... ...... ... ­­----------- ------- ----------------- ---------------­­­ -­------------- -- - ---- -------- -- - ------------------------------- -- -- <br /> --------- --I——------- - ------ ------------ ----------) ­ .. - ­. ------ ---- --------------- ---------------------- - ---------------- ------------ - ------------- <br /> z�--------­ - <br /> FINAL INSPECTION BY:. <br /> ..........­ <br /> ------------- --­-------------- -------r- Date------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 Soufh 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 10-52 Revised W-21W <br />