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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) 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 /> JOB ADDRESS AND LOCATION.-__;W:/<;>— - ----------- <br /> Owner's Name------------- I-ev <br /> --------------------------------- -------------- P h o n <br /> Address..-----------_- <br /> _20 --------------------------- <br /> zc - <br /> Name --------------------------------------------- Pho n .. <br /> Contractor's Na . <br /> .ctor <br /> Installation will serve. Residence -A E]I Apartment House Commercial E] Trailer Court E] Motel Other E] <br /> Number of living units: .Residence <br /> of bedr6.oms --./- Number of baths I--- Lot size ---- <br /> Water.Supply. Public systemCommunity E]system Private E] Depth to Water Table e6 <br /> x 1, ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam E] Clay E] Adobe Hardpan E] <br /> Previous Application Made: Yes JE] No New Construction: Yes ❑ Nox FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPEC'I AICA IONS: <br /> 1 <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> Distance from nearest well___._.___--[--,--Distance from foundation-------------------.Material__-___________--- ---------------------------------- <br /> No.- of compartments--.---- — I I-----Size--•--------------------------------------------------------Liquid depth---------- <br /> .$ ----Capacity----------------------- <br /> u -------- <br /> DixI Field: Distance from nearest well KDistance from fo'ndafion-- 0--- Distance to nearest lot lin e__ __/.... <br /> Number of lines-------- -----Length'of each lir 40----'-------Width of trench Z-5/// <br /> - -- --------------------- <br /> Type of filter material---. Ae--Depth of filter material_*/!;P"` -.-Total length -------------------------- <br /> Seepage7pit: Dis.tlance'to nearest well---- ------Distance from founciafi�'T <br /> on-------------__.Disfance to nearest lot line_____________--- �_ <br /> ❑ Number <br /> of pits------------------- -Lining -Dept[1J--— material-----------------------Size: Diameters-!----' <br /> Cesspool: Distance from nearest wel.I' -- ----------Depth--------------------------------- <br /> -----i-----Distance from foundation-- -- --------1!�Lining material____.___------------ <br /> El Size: Diameter-------- ---------i1 '11 1 '? , I <br /> -,-, ---------------------- ------------------------ ----------- <br /> Liquid Capacity---------------- gals. <br /> - <br /> Privy: Distance.from nearest well ------ ----------- !—___Distance from nearest building <br /> ' - ------------------- <br /> ❑ Distance to nearestlot iin <br /> Remodeling and' I : �7 <br /> /or repairing {describe):_____ " - ----- <br /> ----------- ------- -------------------------- -----;;;a-,---------------1----------------- <br /> L -----------__7---------------------her <br /> herebycertify ----------------------------------------------------------------------------- <br /> f at I ve prepared thi? )plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, <br /> ules <br /> ,And re :o0of !the San Joaquin Local Health District. <br /> (Signed)----------- ------------------------- -------A- ------ --bG -- ------------ -(Owner and/or Contractorl <br /> By:-------------------------------- ---- --- ----- -- ---------- -1- -----------------------------(Title)----- ----------- <br /> (Plot <br /> ........(Plot plan. showing size of of, lots ion of system in relation to w buildings, etc., can 69 placed on reverse side). <br /> FOR DEPARTMENT USE"ONLY <br /> APPLICATION ACCEPTED7 BY--i------------------------------ ---------------------------------- ------------------------- DATE...t�n------ ---•------- <br /> t REVIEWED BY------- ------------------------------- <br /> ---Z---;j--- ----------------------------------------- ------------------ DATE --- ---- ------ <br /> BUILDING PERMIT ISSUED---------------------- --------------------------------hh------------------- --------------------- DATE------- -- ---- --------------*-------------- <br /> -j-- --------7115S ----------- --------------- -------------- <br /> Alterations and/or.recommendaf sons:---------------------------- � k- __ �___ M <br /> ------------- --- ----------------- <br /> 4� 1%--------------- -------f----------------------------------------------------------------------- <br /> ---------------------------------------- - --------------------------------------- ------------------------------- <br /> ----------------------------------------------------------------------------------------------------------- <br /> ---------------------I------------------------------------------------------------------------------------------------�1 <br /> ------- <br /> ------------------------------------------------------------------ -------I-------------- <br /> ---------------I------------------------------------------ ------------- W <br /> ------------------------------------------ ------------------L--- -- ------------------- ------------------------------------------------------- ------------------------------------- <br /> FINAL INSPECTION BY:--' - - ----------- - <br /> _.-I ------------------------------------------------------------�7--------- <br /> --- --- ------------- Date_ <br /> SAN JOAQUIN LOCAL EALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Sf*ckfon, California Lodi, California Manteca, California Tracy, California <br /> ES-9---2M Revised 1-57 F.P.CO, <br />