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3 APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <br /> plication is hereby made to the San Joaquin Local Health District for a permit construct and install the work herein described. <br /> This application is made in compliance with County Ordinance N/o. 5). <br /> JOB ADDRESS AND LOCATION_ ----------- -----If: <br /> --------------- --- --- - -----(,.- ------------------------ ---------- <br /> Owner's Name- 1 Phone. <br /> ��-= ��T - <br /> -------- ---- <br /> Address . . ............... ----------------- --------------------------------------------------------------------------------- <br /> -* <br /> Contractor'sName - <br /> ---- --- -------- -------------------------------------------------- <br /> . ---------------­------------ <br /> Installation will serve: Residence'O Apartment House El Commercial [] Trailer Court E] Motel [] Other E] <br /> / fiNumber-orf living-units: ---T- hunnber of bedrooms..,?-- Number of baths __/--- Lot size ----- 40--------------------- <br /> Water Supply: Public system [] Community system El Private Depth to Water Table 61Wft. <br /> Character of soil to a depth of 3 fee+: Sand E] Gravel E] Sandy Loam 0 Clay Loam L] Clay [] Aclol2le*Hardpan E] <br /> Previous Application Made: Yes E] NX New Construction: YeA No Fj <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> St Tank: Distant m nearest -----------Distance from foundation------------_-----Material------------------------------------------------ <br /> No. of o a ----Size--------------------------------Liquid clepth--------------------------Capacity----------------------- <br /> DiZ Field: Distance from nearest well-)/0 Distance from founclafion-_-Z--- Distance to nearest lot <br /> --------- ---------Width of trench...._.' <br /> Number of lines- /---------------�__._Lengfh of each line_________ I ---- <br /> ----f---------------- <br /> Type of filter mate rialvef_�2�_ ----Depth of filter material__/5?_4__ Total length---------- 3_0-------- ------------ <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 we1-----------------Distance from foundation....................Lining material___._______________________________ ` <br /> ❑ <br /> aterial------------------------------------- <br /> 0 Size. Diameter--------------------------- ----------Depth----•----------------------------------------------Liquid Capacity_.--- -------galls <br /> Privy: Distance from nearest well_______________________________________________Distance from nearest building____....___________________.._.....__._-- <br /> ❑ <br /> uildinq------------------------------------------- <br /> 0 Distance to nearest lot line------- ---------- ----r---------------------------- <br /> ---V---------------------------- --------------- - - -- <br /> --- ------- <br /> Remodeling and/or repairing (describe):------ -4 __"1_w-------------- --- ----------------------------------------------------------------- <br /> ,e <br /> ---------------------------------------------------------------------------I-------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------•-------------•---------------------------------------------------------------------------- ----------------------------------------------- <br /> y <br /> I hereby certify ffhaff I have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> a Tn T <br /> u e f <br /> ordinances, State laws, a ules and ions of fh an aquin Local Health District. <br /> a <br /> ---- --- Own, <br /> -------- --- <br /> f.0 'r <br /> 4oefry item in t <br /> his <br /> to wells, buildings, etc., can be on reverse <br /> ---- --------- -- ------------------------------------------------------------------ Owner an��69ontractor) <br /> (Signed)--------------------_--�1 _ <br /> By:------------------------------------ --- -- ------------- -----------------------------------------------(Title)---------- --- <br /> (Plot plan, showing size of lot, I on e <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ---�_ ---t------ . ..... --------------- DATE___':7—A) <br /> REVIEWED BY-------------------------------- - -- <br /> ------------------------ <br /> --------------------- --------------------- DATE---------------------------------------------------------- <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE. '------------I--------------------------------------- <br /> Alterations and/or recommendations:------------------------------- ------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------- ---------1-------------------------------------- ------------------------------------------------------------ ------------------------------------------------------ <br /> ---------------------- ------------------------------------------------------------------------------------------------ -- ---------------------------------------------------------------------------I---------------------- <br /> ---------------------- ------------------------------------------ ----------------------------------------------------------------------------------------- --------------------------------- <br /> FINAL INSPECTION BY___________________ ---------------------- Date------------------- ----------------- <br /> SAN JOAQUIN LOCAL HPALTH 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 /> ES-9-2M 10-52 Revised W-2100 <br />