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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> This Permit Expires 1 Year From Date Issued 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 C unty Ordinance No. 59. <br /> s <br /> •�. � ff <br /> JOB ADDRESS AND LOCATI N. .0 - � <br /> //O-,v <br /> -------- <br /> �-- / <br /> Owner's Name - -- -----•--Aw <br /> - -------- Phone '7" � <br /> Address--------------- <br /> ------------------------------------ <br /> I <br /> r - ----------------------------------------------------•------------------------------------ <br /> Contractor's Name- . - ------ -----------------------•----------------------------------------- ------ Phone----•-------------------•-----•---- <br /> Installation will serve: Residendce PP Apartment House [3 Commercial [:] Trailer Court ❑< Motel ❑ Other ❑ <br /> Number of living units: L------ Number of bedrooms _'=-_ Number of baths __/-___ Lot size _0� �"" _�_ -_________________________ <br /> Water Supply: Public system prOVI Community system ❑ Private ❑ Depth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel [❑ Sandy Loam ❑ Clay Loam N Clay ❑ Adobe, Hardpan ❑ <br /> Previous Application Made: Yes ❑ No 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_lO-----------Material <br /> � ____-_-__ <br /> - - Q ---- --- __�------- ----------_Capac_i_t <br /> y ------- <br /> No. of compartments--- <br /> Disposal Field: Distance from near t well_,_#V-_____Distance from foundation---/9_____.-___.Distance to nearest lot line-47__._... <br /> Number of lines---- - ____ ength of each line----7�_______________Width of trench__y#4__,--.______.._____--_ <br /> Type of filter mate riai' _lepth of filter material-___/� ______Total length___�-S0_-_______________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__.__-__-__.____ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------_----------------- - <br /> Cesspool: Distance from nearest well----------------- 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 /> Remodelingand/or repairing (describe):---------------------------------------------------------------------------------------------------------------------------------------------------------- { <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 rules and regulations of the San Joaquin Local Health District. <br /> ----------------------------------------------.-.-.(Owner and/or Contractor) <br /> (Signed) �y _t:a._ ` + ----------- <br /> By--------------------------------------------------------------------------------------------------------------------------------------(Title)------ -------- --------------------- ---------------------- I <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). F <br /> FOR DEPARTMENT USE ONLY ��77 <br /> APPLICATION ACCEPTED BY - DATE Is�T- L e�- <br /> ------------- <br /> REVIEWED -BY --------- ----------------------------------------------------- -------------------------- DATE---------------------------- <br /> BUILDING PERMIT ISSUED-------------- ---------------------------------------=----------------------------------------------- DATE. <br /> Alterations and/or recommendations----------------------------- --------------------- <br /> -------------------------------------------------------------------- --------------------------------------------------•---------------------------------------------------:----------------------------------------------- <br /> ------------------------------------------- -------------------------------------- ----------------------------------------------- -----------­-------------------- ----------------------------------------- <br /> FINAL INSPECTION BY:. ,�� ------ -------------- Date__. _ _ - <br /> --- - --- -------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 306 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised 8-'59 F.P.Co. <br />