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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) / S- <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 Ordina No. 9. <br /> JOB ADDRESS ?CATION__________ ___ __ <br /> Owner's Name / ____� --------------------------- --- Phone <br /> / a <br /> Address---7-Q �� <br /> Contractor's Name------------ -- -- --- ------------ ------------- ---------------------------------------------------------------- Prone-------------------- -------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: /-- Number of bedrooms Number of baths -/- Lot size ------------------------- <br /> Water Supply: Public system ❑ Community system ❑ Private U?0'6epth to Water Table k$__Q ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [] Adobe 129-0<ardpan ❑ <br /> Previous Application Made: Yes ❑ No �ew Construction: Yes ❑ No SHA/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 /> c Distance from nearest well_________________Distance from foundation-------------------Material____________________----------------------------------------- ------- <br /> No. of compartments---------- ----------- ---Size-------------------------- ---Liquid depth--------------------------Capacity----------------------- <br /> Disposal Fi Distance from nearest well_sS0t-----Distance from foundation__jQ---------.Distance to nearest lot line------ <br /> of lines_______ g ° _�__-______.Width of trench___.____- -� <br /> ©� �___.___ _ _Len #h of each lin __ -- -_- <br /> Type of filter material.]� epth of finer material______�t __Total length_____,�Z---------------- <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-________________Distance from foundation--------------.----.Lining material:_______-____--______________________. <br /> ❑ Size: Diameter----------------- ------ -------------De th--------------------- ----- - - - ----- ------- ---Liquid Capacity----------------------------glil. <br /> Privy: Distance from nearest well------------------------------------------------- from nearest building_________.__-___-------_____-____.___.._- <br /> ❑ Distance to nearest lot line---------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe):----------------------------------------------------------------------------•---------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------•----------------------------•--------------------------------------------------------------------------------------------------------------- <br /> --------------------- ----------------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------- <br /> I hereb ify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, t i <br /> aws, and rules and regulations of the San Joaquin Local Health District. <br /> Owner and ) <br /> (Signed)------- - -----. `'yA ( /or Contractor <br /> BY=----------- ------ ---------------------------------------------------(Title) ......... <br /> ------------------------- <br /> (Plot plan, showing size of lot, location of tem in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------- <br /> G DATE <br /> REVIEWED BY--------------------------------------------------- -- ----------------------------------- <br /> --------- ------------------------- <br /> BUILDINPERMIT ISSUED---------------------- --------------------------------------- DATE----- <br /> Alterations and/or recommendations--------- ------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ----------------------------•---------------------•-----------------------------------------------_ --------------------------------------------------------•--------------------•---------------------•--------------•---- <br /> ------------------------------------ <br /> ---------------------------------------------------- -- ---- -- -- ------------ -------------------------------------------------------------------------------------------------------------------- <br /> - -- - ------ 1 -----------•--------------------------------•--------------------------------------- --------------------------------- <br /> FINAL INSPECTION- 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 /> E5-4-2M . Revised 1,57 FP.C4- <br />