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APPLICATION FOR SANITATION PERMIT Permit No.,3.. .. ...... <br /> (Complete in Duplicate) <br /> V <br /> 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 Ordinance No. 549. <br /> V-9 <br /> A <br /> V.&4A.Ar <br /> JOB ADDRESS AND LOCATION----- _,_3----------------- ------------------------------------------------ <br /> ----------------------- ------ <br /> Owner's Name-------------- ------------------------ - ---- ---------- ----- j�i,W- 17 <br /> -- -------------------- Phone------ ..... - ------- <br /> Address------------------------------------------------------ ----------------------------------------------- <br /> Contractor's Name-------------------------------- ......r ------•-- ------------------------ ------------ Phone..... <br /> Installation will serve: ResidenceA I <br /> I Apartment House E] ,CommercialE] Trailer Court E] Motel Ej Other ❑ <br /> Number of living units: J--- Number of bedrooms -7--- Number of baths ____/_ Lot size ------- --—------------------- <br /> I <br /> Water Supply: Public system E] Community system F-I Private E]. Depth to Water Table ff. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel L] Sandy Loam L] Clay Loam E], Clay El Adobe Hardpan ❑ <br /> 4;Previous Application Made: Yes E] No;K_ Now Construction: Yes E] No E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> f <br /> tic_jft� Distance from nearest well-----------------Distance from foundation--------------------Material---------r------------------------------------------ <br /> MIA No. of compartmenfs--------------------------Size----------------------------...Liquid cleptk--------------------------Capacity------------------------ <br /> osak&l.d: Distance from nearest well-------------- --Disfance-from foundation--------------------Distance to nearest lot line_______________ <br /> r <br /> Number of lines--- I-----------------------------Length of each line-----_------------------------Width of trench---:------------------------------- <br /> Type of filter material-------------------------Depth o al-----------------------Total length---_--------------------------------_----- <br /> M_ H I <br /> a,_ <br /> lance O)nda i n Tta ce fo nearest lot iine---- <br /> ------------------- <br /> Number of pits-- -------------Linin m '9_si Diameter---- --- Depfn_,._ ;X-111 <br /> Seepage Pit: Distance to nearest well---flm fro <br /> Distan undatio <br /> Cesspool: Distance from nearest well-----------------Distan unclation------------------..Lining material_______._____..____._______--.__._._- <br /> ❑ <br /> aterial-------------------------------------- <br /> El Size: Diameter--------------------------------------Depth--------------------------------------------------Luid Capacity-.---------------------------gals. <br /> F <br /> Privy: Distance from nearest well------- ----------- ----- ----------_--------.-Pistance from neares+ building-------------------------------------- <br /> ❑ Distance to nearest lot line ----------------------------------------------------------------------------------------------------------- <br /> 1 y <br /> Remodelingand/or repairing (describe):-------------------------------------------------------------------------I-----------------------------------------------­­----------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------- ------ -- ---- - <br /> ------- -------------------------------------------------------- ----------------------------------------------------------------------------------:-------------------------------------------------------------------------- <br /> ------------------------------------------------------------------ ---------_1--------------------------------------------------------------------------------------------------------------------- <br /> I her by"Zktify that have payed this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Fpt laws, apd rule d <br /> regulations of +he San Joaquin Local Health District. <br /> (Signed)...... ------------ <br /> - ----- --------- -----------*---- ------------------------------- Contractor) <br /> By:... ------ ---------- i=6� <br /> - ---------------- ---------_(Title)------- ---------------- <br /> ------------------------------------ - ------------------ <br /> (Plot plan, showing s�jze'Of lot, location'of slem in relation to ells, buildings, etc., can be placed on reverse side). <br /> j. FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------­_ DATE_____ <br /> ----------------------------------------------- ----------------------------------- <br /> REVIEWEDBY-------------------------------/ ----------I------------------------------------------------------------------ DATE -•---- <br /> BUILDING <br /> ---BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------- <br /> Alterations and/or recommendations:------------------------------- ----- -----------------....... ------------------------------------------------------------------------------------------------ <br /> -----------------------------­­---------------­------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------- <br /> r,- <br /> ------------------------------------ <br /> --------------------- ------------------ ------------------------- - ------------------------------------------------------------------------------ ------------------------------------------------------------------------- <br /> ------------------------------------------------------------------I----------------------- ------- ------------- ------------------------------------------------------------------------------------------------------------- <br /> FINAL'INSPECTION BY:.,.,-------------------- ----------- - ----------------------- Date------ - - - ---- <br /> , ------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfreet $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 <br />